Business strategy and healthcare

Category Archives: Affordable Care Act

This past week frustration reigned in my office as I saw more cancer patients in one week than I have ever seen in a week. The big problem is that 2 of these patients with advanced disease have no health care insurance or their insurance that they have will not cover their surgery and further treatment. What to do? Wait for the Democrats running for President to give us Medicare for all??

People have to understand that one of the patients has a type of Medicare, however, her policy will not cover further treatment. Remember this for those of you who still believe that Medicare-for-all will solve all our problems.

The other fairly young patient with advanced cancer has a job but no healthcare insurance. But as a dedicated physician, I am going to operate on her in the office only charging her for supplies, which is probably what I will do for the “Medicare type of coverage.

But doctors can’t do this on a routine basis otherwise they couldn’t pay their bills, pay salaries to their staff and pay for their malpractice, healthcare insurance, pay their mortgage and put food on the table. What then? Less and fewer students would choose to go into medicine and care for us all.

And what happens when both of these patients need chemotherapy, radiation treatment, and or immunotherapy? Who is going to pay for their advanced care?

Harris Meyer reported that Healthcare-spending growth would raise at an annual average of 5.5% over the next decade, slightly faster than in the past few years, due to the aging of the baby boomers and healthcare price growth, the CMS Office of the Actuary projects.
Because that growth will exceed gross domestic product growth, the CMS predicts healthcare’s share of GDP will rise from 17.9% in 2017 to 19.4% in 2027, according to a report in Health Affairs released Wednesday. That’s close to the 19.7% the CMS actuary predicted in its last national health expenditure report a year ago.
Price increases are expected to account for nearly half the growth in personal healthcare spending from 2018 to 2027, with an increase in utilization and intensity of services accounting for an additional third of spending growth. The authors of the report said prices will increase by 2.8% for outpatient prescription drugs, 2.6% for hospitals, and 1.8% for physicians.
Overall outpatient drug spending is projected to increase by an average of 6.1% per year over the next decade, driven by increased utilization of new drugs and a modest increase in prices.
These spending trends could boost public support for policy proposals to regulate prices and boost competition for healthcare services and drugs. For instance, Democratic proposals for Medicare-for-all and public plan options would pay providers at Medicare prices, which generally are significantly lower than what private insurers pay.
“The cost trend will make it easier to fund a Medicare-for-all or public option plan, because the price differential between what Medicare and the private sector pay allows you to save money by paying Medicare rates,” said Gerald Anderson, a health policy professor at Johns Hopkins University.
But he and other experts say the projected spending growth over the next decade—which is sharply less than the 7.3% average annual growth from 1990 to 2007—may not be sufficiently alarming to spur politically thorny policy changes.
“There’s nothing here that ought to catch people by surprise,” said Gail Wilensky, a health economist at Project Hope who formerly served as Medicare administrator. “These (projections) offer no reason to celebrate, but they’re not unreasonable. And they’re probably higher than what we’ll actually see because there will be public or private-sector interventions of some sort.”
The projected 5.5% annual rate of growth from 2018 to 2017 would exceed the 5.3% rate during the Affordable Care Act coverage expansion period from 2014 to 2016, as well as the 3.9% growth rate during the Great Recession period of 2008-2013.

Medicare spending is expected to grow faster than Medicaid or private insurance spending due to the aging of the large Baby Boom population into the program, peaking this year. That will produce a 7.4% average annual Medicare spending growth rate over the next decade, compared with 5.5% for Medicaid and 4.8% for private insurance.
Medicaid expenditures will rise partly because of the new Medicaid expansions in Maine and Virginia and expected expansions in Idaho, Nebraska, and Utah.
Per-capita spending growth rates for Medicare, Medicaid, and private insurance are expected to be similar, at 4.7%, 4.1%, and 4.6%, respectively.
The 2017 congressional repeal of the Affordable Care Act’s penalty for not buying insurance, effective this year, will moderate national health spending growth by reducing private insurance enrollment, the report said. That repeal is projected to result in a net increase in the number of uninsured Americans by 1.3 million, to 31.2 million in 2019.
Still, 90.6% of Americans are expected to have coverage in 2019, down from 90.9% last year.
Overall price inflation for healthcare goods and services is expected to average 2.5% over the next decade, compared with 1.1% for 2014 to 2017. The CMS actuaries said prices will rise at least partly because of the weakening of restraining factors such as patient cost sharing, selective contracting by insurers, and improvements in productivity in physicians’ offices.
“Half the growth in spending will be price growth in spite of the fact that all these Baby Boomers are entering Medicare,” said Anderson, citing a famous 2003 Health Affairs article he co-authored. “It’s still the prices, stupid.”
Hospital spending will grow an average of 5.7% per year over the next decade, up from 5.1% in 2019, the actuaries said. Hospital prices will rise due to tighter labor markets and continued wage increases for hospital employees, including nurses.
Average annual spending growth for physician and clinical services is projected at 5.4% for the coming decade, as physician pay is driven up by the shortage of doctors to meet the needs of the aging population.
The economists in the Office of the Actuary who wrote the report acknowledged that their projections can be off for various reasons. For instance, last year they projected that healthcare spending in 2018 would increase by 5.3%. In their new report, they projected spending in 2018 grew only 4.4%.
Sean Keehan, one of the authors, said the 2018 projected spending growth was lowered in the new report due to slower-than-expected Medicaid enrollment and spending increases, smaller out-of-pocket spending hikes, and a more sluggish jump in prescription drug costs.
Anderson said the overall takeaway from the new CMS report is that the U.S. still hasn’t seriously bent the cost growth curve. “There’s no turndown,” he said. “We keep waiting for that turning point and the actuaries aren’t seeing that turning point at least through 2027.”

So, what do we do? Do we listen to the Democrats running for President and wrap our arms around Medicare for All or do we fix the Affordable Care Act or do we design another system?

Seattle Mayor signs Medicare-for-all resolution

Can the left’s ‘free-for-all’ Medicare work?

Fox News Brie Stimson noted that as the national health care debate rages on, Seattle has decided to support Medicare-for-all.

Last month, Seattle Rep. Pramila Jayapal introduced a bill, the Medicare for All Act of 2019, that would transition Americans to single-payer government-paid health care but does not explain how the government will pay for the plan.

This week, Seattle Mayor Jenny Durkan signed a City Council resolution in support of Jayapal’s bill, making Seattle the first city to back a Medicare-for-all bill.

“The U.S. has among the worst health outcomes in the developed world despite spending roughly 19 percent of our nation’s gross domestic product (GDP) on health care,” Seattle Council member. Lorena González said in a statement. “A single-payer system would improve health outcomes while lowering the cost of medical care and insurance.”

Editorial: Medicare for All isn’t the only way to go

Merrill Goozner reported that Healthcare providers and insurers are gearing up to oppose Medicare for All. No surprise there. Insurers can’t look kindly on legislation that would put them out of business. And providers are deathly afraid of losing the high rates from private insurers that cross-subsidize government-funded patients.

But at the same time as they mobilize to defeat M4A, shouldn’t they be outlining what they support?

Here’s what M4A advocates want to achieve. The first is universal coverage. Sadly, we’re again moving away from this basic human right due to actions by the Trump administration to undermine the Affordable Care Act. They want lower prices. Insurance premiums for employers and out-of-pocket expenses for individuals and families continue to rise faster than wages or economic growth.

Finally, they want an end to the frustration engendered by a system that erects roadblocks between physicians and patients. These range from insurer rules requiring prior authorization to seemingly arbitrary limits on what doctors can perform or prescribe.

Is M4A the only way to solve these problems? Of course not. When it comes to covering the uninsured, the ACA worked just fine. Massachusetts, the first state to implement an ACA-like program, had an uninsured rate of 2.5% in 2017. That’s not the 0% of most Organisation for Economic Co-operation and Development countries, but pretty close.

Politics are at the root of the ACA’s failures—not its Rube Goldberg design. The Supreme Court allowed states to opt out of the Medicaid expansion. And when the GOP-controlled Congress eliminated the individual mandate, key to making rates on the exchanges affordable, it reduced sign-ups, raised premiums and stopped the expansion dead in its tracks.

How about service prices? M4A would set prices at Medicare rates, which are well below private insurance rates but higher than Medicaid rates (both Medicaid and the Children’s Health Insurance Program are eliminated in Sen. Bernie Sanders’ M4A bill). But that’s not where most of its savings come from.

According to a sympathetic analysis from the University of Massachusetts at Amherst, half of M4A’s savings come from reducing provider and insurer administrative overhead. Another quarter comes from lower drug prices.

But these are one-time savings that will do little to stop the upward spiral of hospital and physician costs, which account for two-thirds of all spending. That’s where we get to the third issue supposedly addressed by M4A: the administrative hassles and limits imposed on obtaining care.

These aren’t eliminated by an expanded public system. They simply transfer the policing of waste, fraud, and abuse from private hands to public hands and change the motivation from padding profits to protecting taxpayers. In the past, Medicare has done a better job than private payers for one simple reason: it can impose price controls. Providers have responded by shifting much of the shortfall to their private-paying patients.

There are alternatives for achieving M4A’s goals. They include private companies offering exchange policies with well-defined coverage rules and strict limits on out-of-pocket costs; all-payer rate-setting or global budgets to slow the rate of price increases; merging Medicaid with Medicare (leaving long-term services and supports to the states), which would give private employers and families rate and tax relief; and establishing all-stakeholder oversight councils to develop medically appropriate utilization rules.

There’s more. The point is that in the post-Trump era, the U.S. will once again begin moving toward a healthcare system that is universal and affordable with high-quality care for everyone.

A multipayer approach could be like Germany and Switzerland, which rely on private insurers that are regulated to a much greater extent than currently exists in the U.S. Or it will be a single-payer system like Canada, Great Britain or France. Each delivers better results at a lower cost than the U.S.

I’m agnostic on which way to go. I’m still waiting for providers and insurers to articulate their vision.

Some ‘Cheaper’ Health Plans Have Surprising Costs

Julie Appleby reports that one health plan from a well-known insurer promises lower premiums — but warns that consumers may need to file their own claims and negotiate overcharges from hospitals and doctors. Another does away with annual deductibles — but requires policyholders to pay extra if they need certain surgeries and procedures.

Both are among the latest efforts in a seemingly endless quest by employers, consumers, and insurers for an elusive goal: less expensive coverage.

Premiums for many of these plans, which are sold outside the exchanges set up under Affordable Care Act, tend to be 15 to 30 percent lower than conventional offerings, but they put a larger burden on consumers to be savvy shoppers. The offerings tap into a common underlying frustration.

“Traditional health plans have not been able to stem high-cost increases, so people are tearing down the model and trying something different,” said Jeff Levin-Scherz, health management practice leader for benefits consultants Willis Towers Watson.

Not everyone is eligible for a subsidy to defray the cost of an ACA plan, and that has led some people to experiment with new ways to pay their medical expenses. Those experiments include short-term policies or alternatives like Christian-sharing ministries — which are not insurance at all, but rather cooperatives through which members pay one another’s bills.

Now some insurers — such as Blue Cross Blue Shield of North Carolina and a Minnesota startup called Bind Benefits, which is partnering with UnitedHealth Group — are coming up with their own novel offerings.

Insurers say the two new types of plans meet the ACA’s rules, although they interpret those rules in new ways. For example, the new policies avoid the federal law’s rule limiting consumers’ annual in-network limit on out-of-pocket costs. One policy manages that by having no network — patients are free to find providers on their own. And the other skirts the issue by calling additional charges “premiums.” Under ACA rules, premiums don’t count toward the out-of-pocket maximum.

But each plan could leave patients with huge costs in a system in which it is extremely difficult for a patient to be a smart shopper — in part because they have little negotiating power against big hospital systems and partly because the illness is often urgent and unanticipated.

If these alternative plans prompt doctors and hospitals to lower prices, “then that is worth taking a closer look,” says Sabrina Corlette, a research professor at Georgetown University’s Health Policy Institute. “But if it’s simply another flavor of shifting more risk to employees, I don’t think in the long term, that’s going to bend the cost curve.”

Balancing freedom, control, and responsibility

The North Carolina Blue Cross Blue Shield “My Choice” policies aim to change the way doctors and hospitals are paid by limiting reimbursement for services to 40 percent above what Medicare would pay. The plan has no specific network of doctors and hospitals.

This approach “puts you in control to see the doctor you want,” the insurer says on its website. The plan is available to individuals who buy their own insurance and to small businesses with one to 50 employees. It’s aimed at consumers who cannot afford ACA plans, says Austin Vevurka, a spokesman for the insurer. The policies are not sold on the ACA’s insurance marketplace but can be purchased off-exchange from brokers.

With that freedom, however, consumers also have the responsibility to shop around for providers who will accept that amount of reimbursement for their services. Consumers who don’t shop — or can’t because their medical need is an emergency — may get “balance-billed” by providers who are unsatisfied with the flat amount the plan pays.

“There’s an incentive to comparison-shop to find a provider who accepts the benefit,” says Vevurka.

The cost of balance bills range widely but could be thousands of dollars in the case of hospital care. Consumer exposure to balance bills is not capped by the ACA for out-of-network care.

“There are a lot of people for whom a plan like this would present financial risk,” says Levin-Scherz.

In theory, though, paying 40 percent above Medicare rates could help drive down costs over time if enough providers accept those payments. That’s because hospitals currently get about double Medicare rates through their negotiations with insurers.

“It’s a bold move,” says Mark Hall, director of the health law and policy program at Wake Forest University in North Carolina. Still, he says, it’s “not an optimal way” because patients generally don’t want to negotiate with their doctor on prices.

“But it’s an innovative way to put matters into the hands of patients as consumers,” Hall says. “Let them deal directly with providers who insist on charging more than 140 percent of Medicare.”

Blue Cross spokesman Vevurka says My Choice has telephone advisers to help patients find providers and offer tips on how to negotiate a balance bill. He would not disclose enrollment numbers for My Choice, which launched Jan. 1, nor would he say how many providers have indicated they will accept the plan’s payment levels.

Still, the idea — based on what is sometimes called “reference pricing” or “Medicare plus” — is gaining attention. Under that method, hospitals are paid a rate based on what Medicare pays, plus an additional percentage to allow them a modest profit.

North Carolina’s state treasurer, for example, hopes to put state workers into such a pricing plan by next year, offering to pay 177 percent of Medicare. The plan has ignited a firestorm of opposition from hospitals in the state.

Montana recently got its hospitals to agree to such a plan for state workers, paying 234 percent of Medicare, on average.

Partly because of concerns about balance-billing, employers aren’t rushing to buy into Medicare-plus pricing just yet, says Jeff Long, a health care actuary at Lockton Companies, a benefits consultancy.

Wider adoption, however, could spell its end.

Hospitals might agree to participate in a few such programs, but “if there’s more take up on this, I see hospitals possibly starting to fight back,” Long says.

What about the bind?

Minnesota startup Bind Benefits eliminates annual deductibles in its “on-demand” plans sold to employers that are opting to self-insure their workers’ health costs. Rather than deductibles, patients pay flat-dollar copayments for a core set of medical services, from doctor visits to prescription drugs.

In some ways, it’s simpler: There is no need to spend through the deductible before coverage kicks in or wonder what 20 percent of the cost of a doctor visit or surgery would be.

But not all services are included. Does this sound familiar? As I started this post with my examples…ladies and gentlemen, we have a problem!!

Patients who discover during the year that they need any of about 30 common procedures outlined in the plan, including several types of back surgery, knee arthroscopy or coronary artery bypass, must “add in” coverage, spread out over time in deductions from their paychecks.

“People are used to that concept, to buy what they need,” said Bind CEO Tony Miller. “When I need more, I buy more.”

According to a company spokeswoman, the add-in costs vary by market, procedure, and provider. On the lower end, the cost for tonsillectomy and adenoidectomy ranges from $900 to $3,000, while lumbar spine fusion could range from $5,000 to $10,000.

To set those additional premiums, Bind analyzes how much doctors and facilities are paid, along with some quality measures from several sources, including UnitedHealth. The add-in premiums paid by patients vary depending on whether they choose lower-cost providers or more expensive ones.

The ACA’s 2019 out-of-pocket maximums — $7,900 for an individual or $15,800 for a family — don’t include premium costs.

The Cumberland School District in Wisconsin switched from a traditional plan, which it purchased from an insurer for about $1.7 million last year, to Bind. Six months in, according to the school district’s superintendent, Barry Rose, the plan is working well.

Right off the bat, he says, the district saved about $200,000. More savings could come over the year if workers choose lower-cost alternatives for the “add-in” services.

“They can become better consumers because they can see exactly what they’re paying for care,” Rose says.

Levin-Scherz at Willis Towers says the idea behind Bind is intriguing but raises some concerns for employers.

What happens, he asks, if a worker has an add-in surgery, owes several thousand dollars, and then changes jobs before paying all the premiums for that add-in coverage? “Will the employee be sent a bill after leaving?” he wonders.

A Bind spokeswoman says the former employee would not pay the remaining premiums in that case. Instead, the employer would be stuck with the bill.

Next week back to finding a way to improve the Affordable Care Act/ Obamacare.

Here is my question for the week, with all this talk of Medicare for All what happened to Obamacare the pride of the Democratic Party and the Golden Trophy of President Obama?

This was and still is a great idea to provide health care for many/all and was designed by very smart people. The only big problem was how to pay for it and therefore how to make it sustainable, especially after removing the Individual Mandate. Why then Medicare for All with all of its own problems? Susannah Luthi wrote that the Centrist House Democrats on Wednesday launched a push to revive Obamacare stabilization talks, two hours after their progressive wing unveiled new Medicare for All legislation.

But Now Some of the Moderate Democrats revive talks to fund CSRs, reinsurance

The 101-strong New Democrat Coalition wants to fund reinsurance and cost-sharing reduction payments in a package that closely resembles the deal struck last Congress by Senate health committee leaders Lamar Alexander (R-Tenn.) and Patty Murray (D-Wash.).

That bill, known colloquially as Alexander-Murray, fell apart at the last minute following a GOP-Democratic dispute over including anti-abortion language.

“Well, we would call it Schrader-Bera-Kuster,” joked Rep. Kurt Schrader (D-Ore.), one of the co-chairs of the coalition’s healthcare task force as he referred to fellow co-chairs Reps. Ami Bera (D-Calif.) and Annie Kuster (D-N.H.).

He said the group wants to take another run at it, as this is a “different Congress, with different makeup,” and voters gave Congress a mandate to make the individual market more affordable.

To prod leadership into action, the group sent a letter urging prompt committee action to key committee leaders—Frank Pallone (D-N.J.) of Energy and Commerce, Chair Richard Neal (D-Mass.) of Ways and Means, and Bobby Scott (D-Va.) of Education and Labor.

“Building upon your work and the work of the New Democrat Coalition last Congress, we urge your committees to deliver on the promises made to our constituents by prioritizing strengthening the ACA and continuing the path toward universal affordable coverage,” the group wrote.

The group hopes numbers are on their side. It’s now the largest ideological caucus in Congress and owes its swelling ranks to the 40 Democratic freshmen who swept into office largely with the ACA on their platform.

The coalition announced its healthcare policy wish list two hours after progressive Democrats’ 70-minute press conference unveiling the new Medicare for All or single payer legislation.

Coalition members downplayed their role as opposing single payer—highlighting instead the pragmatism of lowering ACA individual market premiums as action Congress can take immediately for people who remain unsubsidized.

They also said they want to discuss public options, such as a policy to allow people to buy into Medicare or Medicaid.

Democratic leaders have pushed support for the ACA as a key part of their agenda, but proposals so far this Congress haven’t included funding for CSRs—whose cut-off led to the silver-loading that boosts premiums for people who can’t get subsidies—or reinsurance.

The Pallone-Neal-Scott proposal from last year includes reinsurance and CSRs, but enthusiasm for funding CSRs has waned since last year. Liberal advocates like the fact that the CSR cut-off led to bigger subsidies for low-income people.

And while insurers hope stabilization talks resurface, their profitability on the exchanges is soaring.

On Wednesday, Pallone told an audience at an Atlantic Live event that he’s most interested in growing the subsidies—increasing the pool of people who qualify for them and raising what’s available for people who currently receive them.

“It’s clear now that people at the higher income level, who were not eligible for those subsidies before, that we need to raise that, for people with a higher income, because there are people now making over $85, $90k a year who don’t get any subsidy,” Pallone said Wednesday morning. “In a place like New Jersey, that’s not a lot of income for a family of four.”

He also confirmed that the House will push back against the Trump administration’s expansion of short-term, limited duration plans.

Pallone was pressed on the cost problem: that an increase in subsidies puts the government on the hook for most of the high premiums, he pointed to his proposal to set up a reinsurance pool.

On whether Congress could overcome last year’s dispute over abortion language, Schrader was optimistic.

However, a Republican aide for the Senate health committee responded by referring to a comment made to Modern Healthcare last week.

“The only way Congress could pass an appropriation for CSRs is if Democrats reverse course and agree to apply the Hyde Amendment which applies to all other healthcare appropriations,” the staffer said.

Dems hit GOP on health care with additional ObamaCare lawsuit vote

At the beginning of January, Jessie Hellmann reported that in the first week of this year the House passed a resolution backing the chamber’s recent move to defend ObamaCare against a lawsuit filed by GOP states, giving Democrats another opportunity to hit Republicans on health care.

GOP Reps. Brian Fitzpatrick (Pa.), John Katko (N.Y.) and Tom Reed (N.Y.) joined with 232 Democrats to support the measure, part of Democrats’ strategy of keeping the focus on the health care law heading into 2020. The final vote tally was 235-192.

While the House voted on Friday to formally intervene in the lawsuit as part of a larger rules package, Democrats teed up Wednesday’s resolution as a standalone measure designed to put Republicans on record with their opposition to the 2010 law.

A federal judge in Texas last month ruled in favor of the GOP-led lawsuit, saying ObamaCare as a whole is invalid. The ruling, however, will not take effect while it is appealed.

Democrats framed Wednesday’s vote as proof that Republicans don’t want to safeguard protections for people with pre-existing conditions — one of the law’s most popular provisions.

“If you support coverage for pre-existing conditions, you will support this measure to try to protect it. It’s that simple,” said Rules Committee Chairman Jim McGovern (D-Mass.) before the vote.

Most Republicans opposed the resolution, arguing it was unnecessary since the House voted last week to file the motion to intervene.

“At best, this proposal is a political exercise intended to allow the majority to reiterate their position on the Affordable Care Act,” said Rep.Tom Cole (R-Okla.). “At worst, it’s an attempt to pressure the courts, but either way, there’s no real justification for doing what the majority wishes to do today.”

The Democratic-led states defending the law are going through the process of appealing a federal judge’s decision that ObamaCare is unconstitutional because it can’t stand without the individual mandate, which Congress repealed.

Democrats were laser-focused on health care and protections for people with pre-existing conditions during the midterm elections — issues they credit with helping them win back the House.

The Trump administration has declined to defend ObamaCare in the lawsuit filed by Republican-led states, which argue that the law’s protections for people with pre-existing conditions should be overturned. It’s unusual for the DOJ to not defend standing federal law.

The House Judiciary Committee, under the new leadership of Chairman Jerrold Nadler (D-N.Y.), plans to investigate why the Department of Justice decided not to defend ObamaCare in the lawsuit.

“The judiciary committee will be investigating how the administration made this blatantly political decision and hold those responsible accountable for their actions,” Nadler said.

Democrats are also putting together proposals to undo what they describe as the Trump administration’s efforts to “sabotage” the law and depress enrollment.

“We’re determined to get that case overruled, and also determined to make sure the Affordable Care Act is stabilized so that the sabotage the Trump administration is trying to inflict ends,” said Rep. Frank Pallone Jr. (D-N.J.), chairman of the Energy and Commerce Committee, which has jurisdiction over ObamaCare.

One of the committee’s first hearings this year will focus on the impacts of the lawsuit. The hearing is expected to take place this month.

The Ways and Means Committee, under the leadership of Chairman Richard Neal (D-Mass), will also hold hearings on the lawsuit and on protections for people with pre-existing conditions.

Those two committees, along with the Education and Labor Committee, are working on legislation that would shore up ObamaCare by increasing eligibility for subsidies, blocking non-ObamaCare plans expanded by the administration and increasing outreach for open enrollment.

And Now the House Democrats Decry ‘Junk Plans’ and are introducing bills to reverse Trump-inflicted ACA “sabotage”

Shannon Firth noted that the Democrats blasted attempts by the Trump administration to “sabotage” the Affordable Care Act during a House Energy & Commerce Health Subcommittee hearing on Wednesday.

“We’re inviting people back into a world with mirrors and trap doors, which was exactly the place we wanted to get away from when we passed the ACA,” said Rep. John Sarbanes (D-Md.), who called on his colleagues to “push back against these junk plans.”

House Democrats introduced four bills to roll back administration efforts to loosen or circumvent the ACA’s insurance requirements. In the very unlikely event that they pass the Republican-controlled Senate and gain the president’s signature, they would:

Require all short-term health plans to include a warning explicitly stating which benefits are included and which aren’t

Restore marketing and outreach funding for ACA exchanges

Rescind a regulation that extended the allowable duration of short-term plans (including renewals) to just under 3 years

Cancel the administration’s new guidance around 1332 waivers, which relaxed certain “guard rails”

Republicans complained that ACA plans are unaffordable for middle-income Americans who don’t receive subsidies, and argued that the Trump administration’s actions allow those same Americans more options for cheaper health plans.

“They’re really trying to give consumers new options, particularly those who were shut out of the market because of costs,” said Grace-Marie Turner, a witness at the hearing and president of the Galen Institute, a conservative think tank, in defense of the administration.

Republicans also pushed back on criticism of the administration’s 1332 waiver guidance, saying Democrats were denying states the right to innovate their programs and instead of trying to impose the will of Washington.

Turner stressed that states are better positioned to regulate their own local health insurance markets.

Rep. Michael Burgess, MD (R-Texas), the subcommittee’s ranking member, said that none of the bills being discussed would increase the availability of “reasonably priced plans.”

Are Short-Term Plans Junk?

Much of Wednesday’s discussion focused on short-term plans, which are cheaper than ACA exchange plans but offer a shrunken set of benefits.

In August, the Trump administration issued a final rule extending the duration of these plans for just under 12 months and made plans eligible for renewals for nearly 3 years. Previously, the plans were available for just under 3 months at a maximum.

Rep. Kathy Castor (D-Fla.), who introduced a bill to rescind the short-term plan rule, said she’s worried “the public is being snookered here.”

“Maybe you were healthy when you signed up. Then, something happens — you have a big medical claim. It triggers an alarm and [the insurers] go back and look at your application, and pull all your medical records again and go, ‘Oh, you should have told us about this,'” she told MedPage Today after the hearing.

Even in cases where a patient was not diagnosed with an illness prior to enrollment, insurers find ways to justify cancellation, she said.

Rep. Nanette Barragán (D-Calif.) offered one example, a Chicago businessman who was encouraged to buy a short-term plan by a broker even after disclosing symptoms of serious back pain. After he enrolled, the businessman was diagnosed with non-Hodgkin lymphoma. Insurers then reviewed his medical records and determined that the businessman’s cancer was a pre-existing condition because he had visited a chiropractor in the past, leaving him with over $800,000 in medical bills after 6 months, Barragán said.

“You would never expect your cancer treatment to be denied because you’ve had bad back pain,” Keith said. “That’s something that, I think, disclosures can’t fix.”

Jessica Altman, Pennsylvania Insurance Department commissioner, pointed out that short-term plans may not cover ACA-defined “essential health benefits.” She cited a study showing that less than 60% cover mental health, only about one-third cover treatment for substance use disorder or prescription drugs, and none included maternity benefits.

Altman also noted that short-term plans aren’t required to abide by the ACA’s medical loss ratio requirements. The two largest short-term plan vendors, which control 80% of the market, spend less than half of each premium dollar on “actual medical care,” she said.

But Turner said short-term plans are meant to serve as “bridge plans” for individuals such as early retirees, people in the gig economy, and young entrepreneurs starting a business, who would convert before long to more comprehensive coverage. Turner also emphasized the plans’ affordability — with premiums less than half of what an ACA plan would cost — and stressed that consumers understand the plans aren’t permanent.

Rep. Richard Hudson (R-N.C.) pointed out that states are allowed to impose limits on short-term plans or ban them altogether.

“I think it’s important to note that we’re not forcing anyone into this. We’re giving flexibility to the states,” he said.

He suggested bringing in witnesses from states where plans are available to learn their true impact.

New Waiver Guidance

Another bill, explored at the hearing, would revoke the administration’s changes to 1332 waivers, which loosened standards for what qualifies as healthcare coverage. The administration’s waiver also allows ACA subsidies to be spent on short-term plans.

Rep. Frank Pallone (D-N.J.), who chairs the full Energy & Commerce Committee, said the changes “turn the statute on its head,” exceeding the administration’s authority and “contrary to congressional intent.”

Keith agreed. She said the guidance was inconsistent with the statute itself. Instead of improving access to healthcare, the guidance “undermines” it. In particular, subsidizing short-term health plans “flies in the face of 1332,” she said.

Several Republicans, including Rep. Greg Walden (R-Ore.), ranking member for the full committee, highlighted the successful implementation of reinsurance programs in states such as Alaska, Minnesota, Oregon, and others, claiming that Democrats oppose state innovation.

Keith clarified that the reinsurance programs were approved under the 1332 rules as written by the previous administration, without the Trump administration’s changes.

Any waivers approved under the Trump administration’s new guidance would likely trigger a lawsuit, she said. As for short-term health plans, several patient advocacy groups have already filed a lawsuit targeting the administration’s new guidance for those plans.

So, I am not going to pursue this issue anymore because I want all of us to consider my first question-Why are Bernie Saunders and most of the multiple Democrat candidates running for President in 2020 touting Medicare for All instead of coming up with fixes for the Affordable Care Act/ Obamacare?

Let us discuss possible fixes to Obamacare next week.

And to a lighter side:

You can now buy an actual hospital room on Amazon

Amazon is increasingly moving into the business of selling supplies to hospitals.

Now, that includes “smart” hospital rooms that can be purchased on its marketplace as of Thursday.

The units are targeted to hospitals and are made by a company called EIR Healthcare.

MedModular

You can buy almost everything on Amazon. And that includes, as of Thursday, a “smart” hospital room in a box.

A New York-based company called EIR Healthcare is now selling units of its hospital room, dubbed MedModular, for $814 a square foot on Amazon.com, which the company claims are more affordable than traditional construction. The design is customizable but all the rooms come with a bathroom and a bed.

These rooms don’t come cheap at $285,000 per unit, but they are targeted to business buyers that are increasingly flocking to Amazon.

So who would buy the units?

“We’re targeting hospitals and health systems,” said Grant Geiger, CEO of EIR Healthcare, the company selling the units. “There’s a trend towards bringing more transparency in the health care space,” he added.

Geiger said he’s currently seeing an uptick in interest from hospitals in using the units for things like simulation labs, or urgent care facilities.

Geiger has also considered looking into potential customers in the military.

But hospital administrators are an obvious place to start, he said, as Amazon is already selling them medical supplies ranging from bedpans to syringes. Previously, large hospital systems would buy everything through group purchasing organizations, or GPOs, which provided discounts but also a lack of transparency around costs.

MedModular

Now, Amazon is looking to carve out its own slice of that lucrative business with its own growing portfolio of medical supplies.

Geiger said he talked to that group for months before he got permission to sell his units on Amazon’s marketplace. He also needed the company’s approval to ship and deliver the product, which involves transporting the units in giant shipping containers down the freeway.

I had to discuss this topic again due to the recent deaths of children who haven’t been vaccinated. It struck a nerve because back, when a friend of mine’s daughter was pregnant, before delivery of our their granddaughter, her future pediatrician, and ObGyn, told her and her husband that all people who came in contact with their future baby should be vaccinated for pertussis, diphtheria etc. Her in-laws said that they were against vaccinations. Their daughter was crushed and she called her father in tears. What to do and what to suggest to their family?

Simple, my suggestion was to tell his daughter to tell the family or have her husband tell his family that if they wanted to visit and see their future niece and granddaughter they needed to be vaccinated or just don’t visit and get a hotel room and then they could see the baby through the glass front door or through the windows. It is about the baby and not about them!

So, when I read the next two articles with the deaths due to measles I was enraged. Parents who are the anti-vaxers, it is about the children and not about their idiot beliefs formed by non-data and from a British physician who had his license taken away.

Dennis Thompson, a HealthDay reporter reported that Measles outbreaks across the United States—including one in Washington state where 50 cases have now been identified—have again shone the spotlight on parents who resist getting kids vaccinated.

These outbreaks are a clear sign of the fraying of “herd immunity,” the overall protection found when a large majority of a population has become immune to a disease, said Dr. Paul Offit. He is director of the Vaccine Education Center at the Children’s Hospital of Philadelphia.

“Measles is the most contagious of the vaccine-preventable diseases, so it’s always the first to come back when you see a drop in herd immunity,” Offit said.

The World Health Organization has taken notice, and recently declared the anti-vaxxer movement a major threat to public health.

Given this, why does anti-vaccine sentiment continue to thrive in certain locales throughout America?

Offit suspects it’s because people have forgotten just how bad diseases like measles, chickenpox and whooping cough can be.

“It’s happening because people aren’t scared of the diseases,” Offit said. “I think vaccines in some ways are victims of their own success.”

But other factors come into play, including a reluctance to give a slew of vaccines to a young child so early in life, now-debunked fears of a link to autism, a feeling that diseases are a natural part of childhood, and a deep-seated distrust of the medical community.

Measles outbreaks were “inevitable,” said Dr. Dawn Nolt, an associate professor of pediatric infectious disease at OHSU Doernbecher Children’s Hospital in Portland, Ore. She lives close to the Washington border, where the biggest current measles outbreaks rage.

“Pockets of communities where there are low vaccine rates are ripe to be ground zero for an outbreak,” Nolt said. “All you need is one person in that community. We knew this was going to happen.”

That’s particularly true of measles, which is incredibly virulent.

Offit explained “you don’t have to have face-to-face contact with someone who has measles. You just have to be within their air space within two hours of their being there.”

According to Nolt, despite its power to spread, there are three questions that typically come up with parents who are hesitant about having their children vaccinated against measles: Is the vaccine safe? Is the vaccine needed? Why shouldn’t I have freedom of choice regarding my child’s vaccinations?

“I think what’s important is to really understand that families have certain concerns and we need to understand those concerns,” Nolt said. “We can’t lump them all together and think that that one conversation serves all of their concerns.”

Parents’ concerns regarding vaccination are often first sparked by the recommended vaccine schedule, Offit said.

“What’s happened is we ask parents of young children in this country to get vaccines to prevent 14 different diseases,” Offit said. “That can mean as many as 26 inoculations during those first few years of life, as many as five shots at one time, to prevent diseases most people don’t see, using biological fluids most people don’t understand.”

So, it’s important that doctors explain to parents that these vaccines are “literally a drop in the ocean” compared to the myriad immune system triggers a child encounters each day, Offit said.

“Very quickly after birth, you have, living on the surface of your body, trillions of bacteria, to which you make an immune response,” Offit explained. “The food you eat isn’t sterile. The dust you inhale isn’t sterile. The water you drink isn’t sterile. You’re constantly being exposed to bacteria to which you make an immune response.”

Doctors also still have to deal with an erroneous 1998 study that linked vaccinations and autism, said Dr. Talia Swartz, an assistant professor of infectious diseases with the Icahn School of Medicine at Mount Sinai, in New York City.

The study was later found to be fraudulent and withdrawn, but “significant press has continued to raise concern about this, even though these concerns have been refuted based on large-scale population studies,” Swartz said.

It’s important to emphasize that these vaccines are heavily tested for safety, said Lori Freeman, CEO of the National Association of County and City Health Officials.

As to whether vaccines are needed, outbreaks provide a powerful argument in favor of that premise, experts said.

However, some parents still greet outbreaks with a shrug.

Nolt said that “some people think vaccines aren’t needed because the disease is more ‘natural’ than the vaccine.”

And arguments based on altruism—vaccinating your child to protect the rest of the community, especially kids who can’t be vaccinated—only go so far, she added.

“I think that resonates with people who have close family or friends who are immunocompromised. For someone who hasn’t had that experience, I think that’s a harder sell,” Nolt said.

Offit is also pessimistic that outbreaks alone will convince hesitant parents to have their kids vaccinated.

“I think children are going to have to die [for attitudes to change],” Offit said. “In regards to measles, you’re probably going to have to get 1,000 to 2,000 cases a year to start to see measles deaths again, but that can happen. Before there was a measles vaccine, which came into the United States in 1963, every year you’d see about 500 children die of measles.”

The “freedom of choice” argument can be the most difficult for doctors to counter, Nolt said. Accumulated distrust of organized medicine, federal regulators and pharmaceutical companies isn’t something a pediatrician can easily counter through conversation.

Now, look at the measles problem in the Philippines!

The Philippines says 136 people have died in a measles outbreak

The Philippine health secretary said Monday that 136 people, mostly children, have died of measles and 8,400 others have fallen ill in an outbreak blamed partly on vaccination fears.

A massive immunization drive that started last week in hard-hit Manila and four provincial regions may contain the outbreak by April, Health Secretary Francisco Duque III said. President Rodrigo Duterte warned in a TV message Friday of fatal complications and urged children to be immunized.

“No ifs, no buts, no conditions, you just have to bring your children and trust that the vaccines … will save your children,” Duque said by telephone. “That’s the absolute answer to this outbreak.”

Infections spiked by more than 1,000 percent in metropolitan Manila, the densely packed capital of more than 12 million people, in January compared to last year, health officials said.

About half of the 136 who died were children aged 1 to 4 and many of those who perished were not inoculated, the officials said.

Duque said a government information drive was helping restore public trust in the government’s immunization program, which was marred in 2017 by controversy over an anti-dengue vaccine made by French drugmaker Sanofi Pasteur which some officials linked to the deaths of at least three children.

The Philippine government halted the anti-dengue immunization drive after Sanofi said a study showed the vaccine may increase the risks of severe dengue infections. More than 830,000 children were injected with the Dengvaxia vaccine under the campaign, which was launched in 2016 under then-President Benigno Aquino III. The campaign continued under Duterte until it was stopped in 2017.

Sanofi officials told Philippine congressional hearings that the Dengvaxia vaccine was safe and effective and would reduce dengue infections if the vaccination drive continued.

“It seems the faith has come back,” Duque said of public trust on the government’s immunization drive, citing the inoculation of about 130,000 of 450,000 people targeted for anti-measles vaccinations in metropolitan Manila in just a week.

Measles is a highly contagious respiratory disease caused by a virus which can be spread through sneezing, coughing and close personal contact.

Complications include diarrhea, ear infections, pneumonia, and encephalitis, or the swelling of the brain, which may lead to death, according to the Department of Health.

A Parent-To-Parent Campaign To Get Vaccine Rates Up

Alex Olgin noted that in 2017, Kim Nelson had just moved her family back to her hometown in South Carolina. Boxes were still scattered around the apartment, and while her two young daughters played, Nelson scrolled through a newspaper article on her phone. It said religious exemptions for vaccines had jumped nearly 70 percent in recent years in the Greenville area — the part of the state she had just moved to.

She remembers yelling to her husband in the other room, “David, you have to get in here! I can’t believe this.”

Up until that point, Nelson hadn’t run into mom friends who didn’t vaccinate.

“It was really eye-opening that this was a big problem,” she says.

Nelson’s dad is a doctor; she had her immunizations, and so did her kids. But this news scared her. She knew that infants were vulnerable — they can’t get started on most vaccines until they are 2 months old. And some kids and adults have diseases that make them unable to get vaccines, so they rely on herd immunity.

Nelson was thinking about public health a lot back then and was even considering a career switch from banking to public health. She decided she had to do something.

“I very much believe if you have the ability to advocate, then you have to,” she says. “The onus is on us if we want to change.”

Like a lot of moms, Nelson had spent hours online. She knew how easy it is to fall down internet rabbit holes and into a world of fake studies and scary stories.

“As somebody who just cannot stand wrong things being on the internet,” Nelson says, “if I saw something with vaccines, I was very quick to chime in ‘That’s not true’ or ‘No, that’s not how that works.’ … I usually get banned.”

Nelson started her own group, South Carolina Parents for Vaccines. She began posting scientific articles online. She started responding to private messages from concerned parents with specific questions. She also found that positive reinforcement was important and would roam around the mom groups, sprinkling affirmations.

Peer-focused groups around the country doing similar work inspired Nelson. Groups with national reach like Voices for Vaccines and regional groups like Vax Northwest in Washington state take a similar approach, encouraging parents to get educated and share facts about vaccines with other parents.

Nationally, 91 percent of children ages 19 to 35 months old have their vaccination for measles, and rates for other vaccinations range from 82 to 92 percent. But in some communities, the rate is much lower. In Clark County, Wash., where a measles outbreak is up to 63 cases, about 76 percent of kindergartners come to school without all their vaccines.

Public health specialists are raising concerns about the need to improve vaccination rates. But efforts to reach vaccine-hesitant parents often fail. When presented with As reported by facts about vaccine safety, parents often remained entrenched in a decision not to vaccinate.

Pediatricians could play a role — and many do — but they’re not compensated to have lengthy discussions with parents, and some of them find it a frustrating task. That has left an opening for alternative approaches, like Nelson’s.

Nelson thought it would be best to zero in on moms who were still on the fence about vaccines.

“It’s easier to pull a hesitant parent over than it is somebody who is firmly anti-vax,” Nelson says. She explains that parents who oppose vaccination often feel so strongly about it that they won’t engage in a discussion. “They feel validated by that choice — it’s part of a community, it’s part of their identity.”

The most important thing is timing: People may need information about vaccines before they become parents. A first pregnancy — when men and women start transitioning into their parental roles — is often when the issue first crops up. Nelson points to one survey study from the Centers for Disease Control and Prevention that showed 90 percent of expectant women had made up their minds on vaccines by the time they were six months pregnant.

“They’re not going to a pediatrician [yet],” Nelson says. “Their OB-GYN is probably not speaking to the pediatric vaccine schedule. … So where are they going? They are going online.”

Nelson tries to counter bad information online with facts. But she also understands the value of in-person dialogue. She organized a class at a public library and advertised the event on mom forums. Nelson was nervous that people opposed to vaccines, whom she calls “anti-vaxxers,” might show up and cause a scene. Vaccine opponents had already banned her from some online forums.

“Are they here to rip me a new one? Or are they here to learn about vaccines?” Nelson wondered. “I just decided, if they’re here I’m going to give them good information.”

Amy Morris was pregnant, but she drove an hour and a half to attend the class. Morris wasn’t the typical first-time mom Nelson was trying to reach. She already had three kids. But during this pregnancy, she was getting increasingly nervous about vaccines. She had recently had a miscarriage, and it was right around the time she had gotten a flu shot. Morris had been reading pro- and anti-vaccine posts in the mom forums and was starting to have some doubts. In Nelson’s class, she learned the risks of not vaccinating.

“That spoke to me more than anything,” said Morris.

Now, holding her healthy 8-month-old son, Thorin, on her lap, she says she’s glad she went because she was feeling vulnerable.

“I always knew it was the right thing to do,” Morris said. “I was listening to that fear monster in the back of my head.”

Nelson says that fear is what the anti-vaccine community feeds on. She has learned to ask questions to help parents get at the root of their anxiety.

“I do think they appreciate it when you meet them sympathetically and you don’t just try and blast facts down their throat,” Nelson said.

Nelson is now trying to get local hospitals to integrate that vaccine talk into their birthing classes. She’s studying for a master’s degree in public health at the University of South Carolina and also works with the Bradshaw Institute for Community Child Health & Advocacy. She’s even considering a run for public office.

House lawmakers to investigate measles outbreak

As reported by our old friend Susannah Luthi, now Congress is wading into the debate over the controversial “philosophical exemption” to immunization, with a key House committee investigation into the recent measles outbreaks that have hit at least 67 people across four states.

The House Energy and Commerce Committee’s oversight panel will hold a bipartisan hearing on the outbreak and response efforts next Wednesday, Feb. 27.

Committee Chair Frank Pallone (D-N.J.) and ranking member Greg Walden (R-Ore.) joined oversight panel Chair Diana DeGette (D-Colo.) and ranking member Brett Guthrie (R-Ky.) in a statement that warned the influx of vaccine-preventable diseases is a serious public health threat.

“Measles is a highly contagious, life-threatening virus that was previously eliminated in the United States thanks to the success of the measles vaccine,” the lawmakers wrote. “Unfortunately, measles cases are on the rise as a consequence of the virus’s transmission among unvaccinated groups.”

The conversation around vaccinations has been escalating inside the Beltway in recent weeks after an initial batch of more than 40 cases of measles was reported in Oregon and Washington state.

In late January, Washington Democratic Gov. Jay Inslee declared a state of emergency due to the outbreak.

Vaccines had eliminated the virus in the U.S. by 2000, but it can return with overseas travelers and spread among the unvaccinated.

Food and Drug Administration Commissioner Dr. Scott Gottlieb has been vocal on Twitter about the public health threat, urging immunizations and suggested to Axios last week that the federal government may have to step in.

In a Tuesday interview on CNN, he elaborated further, warning that if “certain states continue down the path that they’re on, I think they’re going to force the hand of the federal health agencies.”

I believe that the only reason for not vaccinating children should be allergies to a component of the vaccine. We can’t lose any more children to ignorant parents and or incorrect data regarding complications of the vaccines.

So, even if we gave the Democrats everything that they want, where everything including education, money for not working, and of course free health care for all would that solve this problem? I think not!!

It was an interesting week on so many levels. I guess that we don’t have to worry about another government shut down…. until next September but now Congress, the Senate and the President will fight and get nothing done… Probably not even getting the full wall.

Can any progress be made on health care if we have all this anger, incivility and progressive socialism?!? Let’s have progress in health care and vows to work for a better future!

News Editor of MedPage, Joyce Frieden remarked that Congress needs to do a better job of funding public health priorities and improving the healthcare system, a group of six physician organizations told members of Congress.

Presidents of six physician organizations — the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Physicians, the American College of Obstetricians and Gynecologists, the American Osteopathic Association, and the American Psychiatric Association — visited members of Congress as a group here Wednesday to get their message across. The American Medical Association, whose annual Washington advocacy conference takes place here next week, did not participate.

The physician organizations had a series of principles that they wanted to emphasize during their Capitol Hill visits, including:

Helping people maintain their insurance coverage

Protecting patient-centered insurance reforms

Stabilizing the insurance market

Improving the healthcare financing system

Addressing high prescription drug prices

The group also released a list of proposed 2020 appropriations for various federal healthcare agencies, including:

$8.75 billion for the Health Resources and Services Administration

$7.8 billion for the CDC

$460 million for the Agency for Healthcare Research and Quality

$41.6 billion for the National Institutes of Health

$3.7 billion for the Centers for Medicare & Medicaid Services

One of the group’s specific principles revolves around Medicaid funding. “Policymakers should not make changes to federal Medicaid funding that would erode benefits, eligibility, or coverage compared to current law,” the group said in its priorities statement.

This would include programs like the work requirements recently approved in Arkansas and other states; the Kaiser Family Foundation reported in January that more than 18,000 Arkansans have been dropped from the Medicaid rolls for failing to meet the work requirements there.

“Our group is very, very supportive of innovation,” said Ana Maria López, MD, MPH, president of the American College of Physicians, at a breakfast briefing here with reporters. “We welcome testing and evaluation, but we have a very strong tenet that any effort should first do no harm, so any proposed changes should increase — not decrease — the number of people who are insured. Anything that decreases access we should not support.”

That includes work requirements, said John Cullen, MD, president of the American Academy of Family Physicians. “When waivers are used in ways that are trying to get people off of the Medicaid rolls, I think that’s a problem,” he said. “What you want to do is increase coverage.”

Lydia Jeffries, MD, a member of the government affairs committee of the American College of Obstetricians and Gynecologists, agreed. “We support voluntary efforts to increase jobs in the Medicaid population, but we strongly feel that mandatory efforts are against our principal tenets of increasing coverage.”

More $$ for Gun Violence Research

Gun violence research is another focus for the group, which is seeking $50 million in new CDC funding to study firearm-related morbidity and mortality prevention. Kyle Yasuda, MD, president of the American Academy of Pediatrics, explained that gun research stopped in 1997 after the passage of the so-called Dickey Amendment, which prevented the CDC from doing any “gun control advocacy” — that is, accepting for publication obviously biased articles and rejecting any articles that found any positive benefits to gun ownership. Although the amendment didn’t ban the research per se, the CDC chose to comply with it by just avoiding any gun violence research altogether.

Recently, however, Health and Human Services Secretary Alex Azar and CDC Director Robert Redfield, MD, “have provided assurances that the language in the Dickey Amendment would allow for [this] research,” said Yasuda. “We didn’t have research to guide us and that’s what we need to go back to.”

The research is important, said Altha Stewart, MD, president of the American Psychiatric Association, because “in addition to the physical consequences related to gun violence, there’s a long-term psychological impact on everyone involved — both the people who are hurt and the people who witness that hurt. It’s a set of concentric circles that emerges when we talk about the psychological effects of trauma. We often think of [these people] as outliers, but for many people, we work with, this has become all too common in their lives.

“This is definitely our lane as physicians and I’m glad we’re in it,” she said, referring to a popular hashtag on the topic.

Yasuda said the effects of gun violence are nothing new to him because he spent half his career as a trauma surgeon in Seattle. “It’s not just the long-term effect on kids, it is the next generation of kids … It’s the impact on future generations that this exposure to gun violence has on our society, and we just have to stop it.”

The high cost of prescription drugs also needs to be addressed, López said. “We see this every day; people come in and have a list of medications, and you look and see when they were refilled, and see that the refill times are not exactly right … People will say, ‘I can afford to take these two meds on a daily basis, these I have to take once a week’ … They make a plan. [They say] ‘I can fill my meds or I can pay my rent.’ People are making these sorts of choices, and as physicians, it’s our job to advocate for their health.”

One thing the group is staying away from is endorsing a specific health reform plan. “We’re agnostic as far as what a plan looks like, but it has to follow the principles we’ve outlined on consumer protection, coverage, and benefits,” said Cullen. “As far as a specific plan, we have not decided on that.”

Also, Politicians Need To Change The Conversation On How To Fix Health Care

Discussions about Medicare for all, free market care, and Obamacare address one issue – how we pay for health care. The public is tired of these political sound bites and doesn’t have faith in either public or private payment systems to fix their health care woes. Changing the payer system isn’t going to fix the real problem of the underlying cost of care and how it is delivered.

The current system is rotting from the inside. Fee for service payment started the trend with rewarding health care providers for the amount of care they deliver. Through the decades, health care organizations learned how to manipulate the system to maximize profit. Remember, at no time has an insurer lost money. They just increase premiums and decrease reimbursements to health care facilities and caregivers and constrict their coverage. Insurers retaliated by creating more hoops to jump through to get services covered. This includes both Medicare and private insurance.

Who is left to deal with the quagmire? The patients. Additionally, the health care professionals who originally entered their profession to take care of people became burned out minions of the health care machine. Now we are left with an expensive, fragmented health care system that costs three times more than the average costs of other developed countries and has much poorer health outcomes.

Our country needs a fresh conversation on how to fix our health care system. The politicians who can simplify health care delivery and provide a plan to help the most people at a reasonable cost will win the day. There are straightforward fixes to the problem.

About 75% of the population needs only primary care. Early hypertension, diabetes, and other common chronic issues can be easily cared for by a good primary care system. This will reduce the progression of a disease and reduce costs down the line. Unfortunately, the fee for service system has decimated our primary care workforce through turf wars and payment disparities with specialty care and we now have a severe primary care shortage. Patients often end up with multiple specialists which increases cost, provides unsafe and fragmented care, and decreases patient productivity.

Insurance is meant to cover only high cost or rare events. Primary care is inexpensive and is needed regularly, so it is not insurable. We pay insurance companies 25% in overhead for the privilege of covering our primary care expenses. Plus, patients and their doctors often must fight insurance companies to get services covered. The lost productivity for patients and care providers is immeasurable.

In a previous article, the author shared the proposal of creating a nationalized network of community health centers to provide free primary care, dental care, and mental health care to everyone in this country.

Community health centers currently provide these services for an average cost of less than $1,000 per person per year. By providing this care free to all, we can remove primary care from insurance coverage, which would reduce the cost of health insurance premiums.

Free primary care would improve population health, which will subsequently reduce the cost of specialty care and further reduce premiums.

Community health centers can serve as treatment centers for addiction, such as our current opioid crisis, and serve as centers of preparedness for epidemic and bioterrorist events.

People who do not want to access a community health center can pay for primary care through direct primary care providers.

This idea is not unprecedented – Spain enacted a nationwide system of community health centers in the 1980s. Health care measures, patient satisfaction, and costs improved significantly.

By providing a free base of primary care, dental care, and mental health care to everyone in this country, we can improve health, reduce costs, and improve productivity while we work toward fixing our health care payment system.

Current Community Health Centers

Community health centers currently serve approximately 25 million low-income patients although they have the structural capacity to serve many more. This historical perspective of serving low-income individuals may be a barrier to acceptance in the wider population. In fact, when discussing this proposal with a number of health economists and policy people, many felt the current variability in the quality of care would discourage use of community health centers in all but a low-income population. Proper funding, a culture of care and accountability, and the creation of a high functioning state of the art facilities would address this concern.

There are currently a number of community health centers offering innovative care, including dental and mental health care. Some centers use group care and community health workers to deliver care to their communities. Many have programs making a serious dent in fighting the opioid epidemic. Taking the best of these high functioning clinics and creating a prototype clinic to serve every community in our nation is the first step in fixing our health care system

The Prototype Community Health Center – Delivery of Care

Community health centers will be built around the patient’s needs. Each clinic should have:

Extended and weekend hours to deliver both acute and routine primary care, dental care, and mental health care. This includes reproductive and pediatric care.

Home visits using community health workers and telemedicine to reach remote areas, homebound, and vulnerable populations such as the elderly.

A pharmacy that provides generic medications used for common acute and chronic illnesses. Medication will be issued during the patient’s visit.

There will be no patient billing. Centers will be paid globally based on the population they serve.

The standard of care will be evidence-based for problems that have evidence-based research available. If patients desire care that is not evidence based, they can access it outside the community health system and pay for that care directly. For problems that do not have evidence-based research, basic standards of care will apply.

It will be very important that both providers and patients understand exactly what services will be delivered. By setting clear expectations and boundaries, efficiency can be maintained and manipulation of the system can be minimized.

The Prototype Community Health Center – Staffing

The clinics would be federally staffed and funded. Health care providers and other employees will receive competitive salary and benefits. To attract primary care providers, school loan repayment plans can be part of the compensation package.

The “culture” of community health centers must be codified and will be an additional attraction for potential employees. A positive culture focused on keeping patients AND staff healthy and happy, open communication, non-defensive problem solving, and an attitude of creating success should be the standard. Bonuses should be based on the quality of care delivery and participation in maintaining good culture.

One nationalized medical record system will be used for all community health centers. The medical records will be built solely for patient care. Clinical decision support systems can be utilized to guide health care providers in standards of diagnosis and treatment, including when to refer outside the system.

Through the use of telemedicine, basic consultation with specialists can be provided but specialists will consult with the primary care physicians directly. One specialist can serve many clinics. For example, if a patient has a rash that is difficult to diagnose, the primary care doctor will take a picture and send it to the dermatologist for assistance.

For services beyond primary care and basic specialty consultation, insurance will still apply. The premiums for these policies will be much lower because primary care will be excluded from coverage.

How to get “there” from “here”

Think Starbucks – after the development of the prototype design based on currently successful models, with proper funding, centers can be built quickly. Attracting primary care providers, dentists, and mental health care providers will be key to success.

Basic services can be instituted first – immunizations, preventive care, reproductive care, and chronic disease management programs can be standardized and easily delivered by ancillary care providers and community health workers. Epidemic and bioterrorist management modules can be provided to each center. As the primary care workforce is rebuilt, further services can be added such as acute care visits, basic specialty consultations, and expanded dental and mental health care.

With the implementation of this primary care system, payment reform can be addressed. Less expensive policies can immediately be offered that exclude primary care. Ideally, we will move toward a value-based payment system for specialty care. The decision on Medicare for all, a totally private payer system, or a public and private option can be made. Thankfully, during the political discourse, 75% of the population will have their needs fully met and our country will start down the road to better health.

Christopher Zara reported that in today’s edition of “Ask and Ye Shall Receive,” here’s more evidence that support for universal health care isn’t going away.

The Twitter account for Fox & Friends this week ran a poll in which it asked people if the benefits of Bernie Sanders’s “Medicare for All” plan would outweigh the costs. The poll cites an estimated cost of $32.6 trillion. Hilariously, 73% of respondents said yes, it’s still worth it—which is not exactly the answer you’d expect from fans of the Trump-friendly talk show.

Granted, this is just a Twitter poll, which means it’s not scientific and was almost certainly skewed by retweets from Twitter users looking to achieve this result.

At the same time, it’s not that far off from actual polling around the issue. In March, a Kaiser Health tracking poll revealed that 6 in 10 Americans are in favor of a national healthcare system in which all Americans would get health insurance from a single government plan. Other polls have put the number at less than 50% support but trending upward.

If you’re still unsure, you can read more about Sanders’s plan and stay tuned for more discussion on “Medicare for All”.

Should we all be even concerned about any of these health care problems if AOC is right and the world ends in 12 years? Good young Ocasio Cortez, if she only had ahold on reality!! Her ideas will cost us all trillions of dollars, tax dollars, which we will all pay! Are we all ready for the Green Revolution?

Actually, I thought that President Trump did a good job even being conciliatory in his State of the Union speech even covering various aspects of healthcare. Joyce Frieden the News Editor of MedPage stated that Healthcare played a major part in Tuesday’s State of the Union address, with President Trump covering a wide variety of health-related topics.

Only a few minutes into the speech, the president foreshadowed some of his healthcare themes. “Many of us have campaigned the same core promises to defend American jobs and … to reduce the price of healthcare and prescription drugs,” Trump said. “It’s a new opportunity in American politics if only we have the courage together to seize it.”

A few minutes later, he touted some of his administration’s actions so far. “We eliminated the very unpopular Obamacare individual mandate penalty,” Trump said. “And to give critically ill patients access to lifesaving cures, we passed — very importantly — the right to try.”

Drug Prices a Major Player

The subject of drug prices occupied a fair amount of time. “The next major priority for me, and for all of us, is to lower the cost of healthcare and prescription drugs and to protect patients with preexisting conditions,” he said. “Already, as a result of my administration’s efforts in 2018, drug prices experienced their single largest decline in 46 years. But we must do more. It’s unacceptable that Americans pay vastly more than people in other countries for the exact same drugs, often made in the exact same place.”

“This is wrong; this is unfair, and together we will stop it, and we’ll stop it fast,” he said. “I am asking the Congress to pass legislation that finally takes on the problem of global freeloading and delivers fairness and price transparency for American patients, finally.”

He then turned to several other health topics. “We should also require drug companies, insurance companies, and hospitals to disclose real prices, to foster competition, and bring costs way down,” Trump said. He quickly moved on to the AIDS epidemic. “In recent years we’ve made remarkable progress in the fight against HIV and AIDS. Scientific breakthroughs have brought a once distant dream within reach. My budget will ask Democrats and Republicans to make the needed commitment to eliminate the HIV epidemic in the United States within 10 years.”

“We have made incredible strides, incredible,” he added to applause from members of Congress on both sides of the aisle. “Together we will defeat AIDS in America and beyond.”

Childhood Cancer Initiative

Although the remarks on HIV had been expected, the president also announced another health initiative that wasn’t as well-known: a fight against childhood cancer. “Tonight I’m also asking you to join me in another fight all Americans can get behind — the fight against childhood cancer,” he said, pointing out a guest of First Lady Melania Trump: Grace Eline, a 10-year-old girl with brain cancer.

“Every birthday, since she was 4, Grace asked her friends to donate to St. Jude’s Children’s Hospital,” Trump said. “She did not know that one day she might be a patient herself [but] that’s what happened. Last year Grace was diagnosed with brain cancer. Immediately she began radiation treatment, and at the same time she rallied her community and raised more than $40,000 for the fight against cancer.”

“Many childhood cancers have not seen new therapies in decades,” he said. “My budget will ask Congress for $500 million over the next 10 years to fund this critical life-saving research.”

These health initiatives met with mixed reactions. “President Trump is taking a bold step to design an innovative program and strategy, and commit new resources, to end HIV in the United States … Under the President’s proposal, the number of new infections can eventually be reduced to zero,” Carl Schmid, deputy executive director of The AIDS Institute, said in a statement. Michael Ruppal, the institute’s executive director, added, “While we might have policy differences with the president and his administration, this initiative if properly implemented and resourced, can go down in history as one of the most significant achievements of his presidency.”

But the Democratic National Committee (DNC) wasn’t quite so enthusiastic; it sent an email calling the goal of ending HIV by 2030 “notable” but added, “The Trump administration has consistently undermined advancements in HIV/AIDS research, attacked people living with HIV/AIDS, and sabotaged access to quality healthcare at every opportunity.” Among other things, the administration redirected money from the Ryan White HIV/AIDS Program to help fund the separation of immigrant families, and proposed cutting global HIV/AIDS funding by over $1 billion, which could cause 300,000 deaths per year, the DNC said.

Abortion in the Spotlight

As for the childhood cancer initiative, “$500 million over 10 years to solve childhood cancer is … not a lot,” one Bloomberg reporter tweeted. However, Gail Wilensky, Ph.D., a senior fellow at Project HOPE, in Bethesda, Maryland, pointed out that this amount ” is in addition to the National Institutes of Health budget [for cancer] … A lot of money is going to cancer anyway [already] and the National Cancer Institute been one of the more protected parts of government, so it’s not like they have a big deficit to make up.”

Overall, “it was a surprisingly good speech,” said Wilensky, who was the administrator of the Centers for Medicare & Medicaid Services under President George H.W. Bush. “It covered a lot of areas, and there were a number of issues that were very hard not to applaud … I thought he did a pretty admirable job of forcing applause and a sense of togetherness by the country, talking about compromise and the common good.”

The president also touched on a more controversial area of healthcare: abortion. He referred to a recent abortion bill that passed in New York State and another that failed in Virginia — both of which dealt with abortion late in pregnancy — adding, “I’m asking Congress to pass legislation to prohibit late-term abortion of children who can feel pain in a mother’s womb. Let us work together to build a culture that cherishes innocent life.”

That appeal to the anti-abortion movement “is a position that Republicans have taken in the past, which is the importance of life right after birth and life right before birth,” said Wilensky. Abortion later in pregnancy “is an area that tends to engender a more unified response than most others, even for people who are ambivalent or more supportive of abortion rights. Very late-term abortion makes people uncomfortable … It’s easy to understand why people get uneasy.”

“Already, the biggest move the Trump administration has made to control health care costs and access has been on the regulatory front,” said Bob Laszewski, founder of Health Policy and Strategy Associates, an Alexandria, Virginia, consulting firm, citing the announcement of proposed regulations to end drug rebates under Medicare and Medicaid kickback rules and rules for short-term health plans. “I take it from Trump’s remarks that they will continue with this regulatory approach instead of waiting for any bipartisanship in the Congress,” he said.

“The only area there now seems to be a hint of bipartisanship is over the issue of drug prices being too high,” Laszewski added. “It was clear from Trump’s remarks, and the Democrats’ positive response on this one issue, that this could become an area for cooperation.”

No Large-Scale Reforms Offered

Rosemarie Day, a healthcare consultant in Somerville, Massachusetts, said in an email that the president “certainly did not propose any large-scale reforms to the healthcare system during the speech, and he was short on specifics for most of it. According to a recent Kaiser Family Foundation poll, health care is the number one issue among voters so this may appear to some as a missed opportunity. It’s increasingly looking like Republicans are leaving the big health care reform ideas to the Democratic presidential candidates.”

The ideas he did propose “were mostly noncontroversial and somewhat vague,” Day continued. “The more interesting proposal was lowering the cost of healthcare and drugs, which is a high priority for consumers. The way he discussed going about it was by requiring drug companies, insurance companies, and hospitals to disclose real prices. This raises many questions, such as what does a ‘real’ price mean? … This will be an interesting area to watch, since ‘real prices’ are currently closely held secrets, and a legal requirement to disclose them would constitute a significant change from the status quo.”

In the Democratic response to the speech, Stacey Abrams, a Democrat who ran unsuccessfully last year for governor of Georgia, lashed out against enemies of Obamacare. “Rather than suing to dismantle the Affordable Care Act as Republican attorneys general have, our leaders must protect the progress we’ve made and commit to expanding healthcare and lowering costs for everyone,” said Abrams, the first black woman to deliver the rebuttal to a State of the Union address.

She also spoke of her personal struggle with healthcare costs for her family. “My father has battled prostate cancer for years. To help cover the costs, I found myself sinking deeper into debt because, while you can defer some payments, you can’t defer cancer treatment. In this great nation, Americans are skipping blood pressure pills, forced to choose between buying medicine and paying rent.”

She also pushed back against state governors and legislators who continue their resistance to Medicaid expansion. “In 14 states, including my home state, where a majority want it, our leaders refused to expand Medicaid which could save rural hospitals, save economies and save lives.”

With Dems now in charge, repeal-and-replace no longer on the table!

Former Rep. John Dingell Left An Enduring Health Care Legacy

If anyone is interested in healthcare and its history here in the U.S. one must include the legacy of former Rep. John Dingell, the Michigan Democrat who holds the record as the longest-serving member of the U.S. House, died Thursday night in Michigan. Julie Rovner reviewed his history last week after his death. He was 92.

And while his name was not familiar to many, his impact on the nation, and on health care, in particular, was immense.

For more than 16 years Dingell led the powerful House Energy and Commerce Committee, which is responsible for overseeing the Medicare and Medicaid programs, the U.S. Public Health Service, the Food and Drug Administration and the National Institutes of Health.

Dingell served in the House for nearly 60 years. As a young legislator, he presided over the House during the vote to approve Medicare in 1965.

As a tribute to his father, who served before him and who introduced the first congressional legislation to establish national health insurance during the New Deal, Dingell introduced his own national health insurance bill at the start of every Congress.

And when the House passed what would become the Affordable Care Act in 2009, leaders named the legislation after him. Dingell sat by the side of President Barack Obama when he signed the bill into law in 2010.

Dingell was “a beloved pillar of the Congress and one of the greatest legislators in American history,” said a statement from House Speaker Nancy Pelosi. “Yet, among the vast array of historic legislative achievements, few hold greater meaning than his tireless commitment to the health of the American people.”

He was not always nice. Dingell had a quick temper and a ferocious demeanor when he was displeased, which was often. Witnesses who testified before him could feel his wrath, as could Republican opponents and even other committee Democrats. And he was fiercely protective of his committee’s territory.

In 1993, during the effort by President Bill Clinton to pass major health reform, as the heads of the three main committees that oversee health issues argued over which would lead the effort, Dingell famously proclaimed of his panel, “We have health.”

Dingell and his health subcommittee chairman, California Democrat Henry Waxman, fought endlessly over energy and environmental issues. Waxman, who represented an area that included western Los Angeles, was one of the House’s most active environmentalists. Dingell represented the powerful auto industry in southeastern Michigan and opposed many efforts to require safety equipment and fuel and emission standards.

In 2008, Waxman ousted Dingell from the chairmanship of the full committee.

But the two were of the same mind on most health issues, and together during the 1980s and early 1990s they expanded the Medicaid program, reshaped Medicare and modernized the FDA, NIH and the Centers for Disease Control and Prevention.

“It was always a relief for me to know that when he and I met with the Senate in the conference, we were talking from the same page, believed in the same things, and we were going to fight together,” Waxman said in 2009.

Dingell was succeeded in his seat by his wife, Rep. Debbie Dingell, herself a former auto industry lobbyist.

House Panel Mulls ACA Fixes, Responses to Trump Policies

Now to the article of the week, Ryan Basen, a writer for MedPage noted that focusing on preventive care, expanding subsidies, and regulating association health plans (AHPs) were among the solutions proposed Tuesday to aid Americans with pre-existing health conditions, as the U.S. House Ways and Means Committee held its first hearing under the new Congress.

While the hearing was entitled “Protecting Americans with Pre-Existing Conditions,” much discussion centered around the policies within the Affordable Care Act, Republican efforts to repeal it, and recent reforms that tweaked American healthcare. Many lawmakers used their allotted time to blast other party members for either being too supportive of the ACA or attempting to “sabotage” it. Some lawmakers, however, promised to work together with members of the opposing party to help patients with pre-existing conditions — which some noted includes themselves and family members.

“Protections for people with pre-existing conditions has become the defining feature of the Affordable Care Act,” said witness Karen Pollitz, a senior fellow with the Kaiser Family Foundation; she noted that these protections also enjoy widespread public support.

The ACA forced insurance plans to accept and retain members with pre-existing conditions, many of whom could not afford plans before the legislation was enacted. But Trump administration policies and other reforms worry some experts and lawmakers that the millions of American with pre-existing conditions — ranging from moderate mental health diagnoses to cancer — are gradually being priced out of the healthcare system again, they said.

Protecting patients with pre-existing conditions are linked to controlling costs throughout American healthcare, many said. Recent legislation led to “artificial” cost increases for ACA marketplace plans and pushed some insurers to leave the market altogether, Pollitz said. These policies also have driven up premium prices.

“What we have here is an infrastructure problem,” Rep. John Larson (D-Conn.) said. “The disagreements are over how to pay for it.”

“All we are really debating here is who gets to pay,” Rep. David Schweikert (R-Ariz.) said. “It’s time for radical rethinking: Are you [Democrats] willing to work with us to break down the barriers to having cost disruption?”

Several who spoke Tuesday offered potential solutions. Witness Keysha Brooks-Coley, of the American Cancer Society Cancer Action Network, suggested lawmakers strengthen the ACA by addressing its so-called “family glitch” and eliminating the “subsidy cliff”; both policies currently withhold subsidies from many Americans who need them to pay for healthcare, she said.

Rep. Brad Wenstrup, DPM (R-Ohio), called for turning lawmakers’ focus from squabbling about politics to studying preventative care. “There’s no part of me as a doctor that doesn’t want Americans to have access to quality healthcare,” the podiatrist said. “But I don’t necessarily agree with the direction (the ACA) went.”

“Let’s talk about incentivizing health: What do we have not only for the patient but for the physician?” he added. “Think about who gets rewarded in today’s system. Do we recognize the doctor who prevented the patient from needing open-heart surgery? That’s where we need to go if you want to talk about the cost curve.”

One solution is actually quite simple, according to witness Rob Roberston, secretary-treasurer for the Nebraska Farm Bureau: regulate AHPs and encourage individuals to band together in groups to reduce premium costs, as many farmers and ranchers have in Nebraska. “This is not a political issue,” he said. “This is an issue of hardship, and we need to fix these individual markets and protect pre-existing conditions at the same time.”

Alas, judging by many lawmakers’ tone during a hearing that stretched over four hours, this does appear to be a political issue. “It’s really this long debate over Obamacare,” Rep. Devin Nunes (R-Calif.) said. “We really need to work for a solution because Obamacare wasn’t a solution.”

Rep. Lloyd Doggett (D-Texas) then got into it. “What has led us here has been eight years of Republican persistence in trying to destroy the Affordable Care Act,” he said. “It’s great to hear they [Republicans] want to work with us and I hope they do.” The ACA is not perfect, Doggett acknowledged, but he quipped that perhaps “the most pre-existing condition” present Tuesday was “the political amnesia of those who have forgotten what it was like before the Affordable Care Act.”

Raising his voice, Rep. Earl Blumenauer (D-Ore.) echoed the point: “If we would have been working together for the last six years to refine the Affordable Care Act, costs would be lower, coverage would be better.”

Many witnesses spoke against the Administration’s policy to loosen regulations on cheaper short-term plans that do not have to abide by ACA strictures. “The expansion of these plans does not help the consumer,” Brooks-Coley said. “It puts them at increased risk. … They are only less expensive upfront because they don’t cover [serious conditions].” In addition, Pollitz noted, many of these plans drop patients once they become ill and “have been shown to increase costs of ACA-compliant plans.”

The witnesses were asked to gauge what would happen if protections for patients with pre-existing conditions were to be removed. Younger women would pay more than men the same age, Pollitz said, and all pre-existing patients “would find it much more difficult to find coverage.”

“True harm would come,” Andrew Stolfi, Oregon Division of Financial Regulation’s insurance commissioner, told the committee. He cited Oregon’s pre-ACA experience: “You were lucky if you were even given the choice to take an insurer’s limited terms.”

Ways and Means chairman Richard Neal (D-Mass.) ended the hearing with optimism: “Today I heard a lot of members on the other side of the aisle say they support [requiring coverage for] pre-existing conditions, and I welcome that and hope we can work together.”

So, now what do the physicians think is needed to improve our health care system? Next week let’s discuss.

So, one of the options that the Democrats are pushing is “Medicare-for-All.” But do the voters like the idea? Ricardo Alonso-Zaldivar noted that Americans like the idea of “Medicare-for-all,” but support flips to disapproval if it would result in higher taxes or longer waits for care. Then how will the plan be financed?

That’s a key insight from a national poll released Wednesday by the nonpartisan Kaiser Family Foundation. It comes as Democratic presidential hopefuls embrace the idea of a government-run health care system, considered outside the mainstream of their party until Vermont independent Sen. Bernie Sanders made it the cornerstone of his 2016 campaign. President Donald Trump is opposed, saying “Medicare-for-all” would “eviscerate” the current program for seniors.

The poll found that Americans initially support “Medicare-for-all,” 56 percent to 42 percent.

However, those numbers shifted dramatically when people were asked about the potential impact, pro, and con.

Support increased when people were told “Medicare-for-all” would guarantee health insurance as a right (71 percent) and eliminates premiums and reduce out-of-pocket costs (67 percent).

But if they were told that a government-run system could lead to delays in getting care or higher taxes, support plunged to 26 percent and 37 percent, respectively. Support fell to 32 percent if it would threaten the current Medicare program.

“The issue that will really be fundamental would be the tax issue,” said Robert Blendon, a professor at the Harvard T.H. Chan School of Public Health who reviewed the poll. He pointed out those state single-payer efforts in Vermont and Colorado failed because of concerns about the tax increases needed to put them in place.

There doesn’t seem to be much disagreement that a single-payer system would require tax increases since the government would take over premiums now paid by employers and individuals as it replaces the private health insurance industry. The question is how much.

Several independent studies have estimated that government spending on health care would increase dramatically, in the range of about $25 trillion to $35 trillion or more over a 10-year period. But a recent estimate from the Political Economy Research Institute at the University of Massachusetts in Amherst suggests that it could be much lower. With significant cost savings, the government would need to raise about $1.1 trillion from new revenue sources in the first year of the new program.

House Budget Committee Chairman John Yarmuth, D-Ky., has asked the Congressional Budget Office for a comprehensive report on single-payer. The CBO is a nonpartisan outfit that analyzes the potential cost and impact of legislation. Its estimate that millions would be made uninsured by Republican bills to repeal the Affordable Care Act was key to the survival of President Barack Obama’s health care law.

Mollyann Brodie, director of the Kaiser poll, said the big swings in approval and disapproval show that the debate over “Medicare-for-all” is in its infancy. “You immediately see that opinion is not set in stone on this issue,” she said.

Indeed, the poll found that many people are still unaware of some of the basic implications of a national health plan.

For example, most working-age people currently covered by an employer (55 percent) said they would be able to keep their current plan under a government-run system, while 37 percent correctly answered that they would not.

There’s one exception: Under a “Medicare-for-all” idea from the Center for American Progress employers and individuals would have the choice of joining the government plan, although it wouldn’t be required. Sanders’ bill would forbid employers from offering coverage that duplicates benefits under the new government plan.

“Medicare-for-all” is a key issue energizing the Democratic base ahead of the 2020 presidential election, but Republicans are solidly opposed.

“Any public debate about ‘Medicare-for-all’ will be a divisive issue for the country at large,” Brodie said.

The poll indicated widespread support for two other ideas advanced by Democrats as alternatives to a health care system fully run by the government.

Majorities across the political spectrum backed allowing people ages 50-64 to buy into Medicare, as well as allowing people who don’t have health insurance on the job to buy into their state’s Medicaid program.

Separately, another private survey out Wednesday finds the uninsured rate among U.S. adults rose to 13.7 percent in the last three months of 2018. The Gallup National Health and Well-Being Index found an increase of 2.8 percentage points since 2016, the year Trump was elected promising to repeal “Obamacare.” That would translate to about 7 million more uninsured adults.

Government surveys have found that the uninsured rate has remained essentially stable under Trump.

The Kaiser Health Tracking Poll was conducted Jan. 9-14 and involved random calls to the cellphones and landlines of 1,190 adults. The margin of sampling error for all respondents is plus or minus 3 percentage points.

Trump Seeks Action To Stop Surprise Medical Bills

A healthcare reporter, Emmarie Huettman reported that President Trump instructed administration officials Wednesday to investigate how to prevent surprise medical bills, broadening his focus on drug prices to include other issues of price transparency in health care.

Flanked by patients and other guests invited to the White House to share their stories of unexpected and outrageous bills, Trump directed his health secretary, Alex Azar, and labor secretary, Alex Acosta, to work on a solution, several attendees said.

“The pricing is hurting patients, and we’ve stopped a lot of it, but we’re going to stop all of it,” Trump said during a roundtable discussion when reporters were briefly allowed into the otherwise closed-door meeting.

David Silverstein, the founder of a Colorado-based nonprofit called Broken Healthcare who attended, said Trump struck an aggressive tone, calling for a solution with “the biggest teeth you can find.”

Surprise billing, or the practice of charging patients for care that is more expensive than anticipated or isn’t covered by their insurance, has received a flood of attention in the past year, particularly as Kaiser Health News, NPR, Vox and other news organizations have undertaken investigations into patients’ most outrageous medical bills.

Attendees said the 10 invited guests — patients as well as doctors — were given an opportunity to tell their story, though Trump didn’t stay to hear all of them during the roughly hourlong gathering.

The group included Paul Davis, a retired doctor from Findlay, Ohio, whose daughter’s experience with a $17,850 bill for a urine test after back surgery was detailed in February 2018 in KHN-NPR’s first Bill of the Month feature.

Davis’ daughter, Elizabeth Moreno, was a college student in Texas when she had spinal surgery to remedy debilitating back pain. After the surgery, she was asked to provide a urine sample and later received a bill from an out-of-network lab in Houston that tested it.

Such tests rarely cost more than $200, a fraction of what the lab charged Moreno and her insurance company. But fearing damage to his daughter’s credit, Davis paid the lab $5,000 and filed a complaint with the Texas attorney general’s office, alleging “price gouging of staggering proportions.”

Davis said White House officials made it clear that price transparency is a “high priority” for Trump, and while they didn’t see eye to eye on every subject, he said he was struck by the administration’s sincerity.

“These people seemed earnest in wanting to do something constructive to fix this,” Davis said.

Dr. Martin Makary, a professor of surgery and health policy at Johns Hopkins University who has written about transparency in health care and attended the meeting, said it was a good opportunity for the White House to hear firsthand about a serious and widespread issue.

“This is how most of America lives, and [Americans are] getting hammered,” he said.

Trump has often railed against high prescription drug prices but has said less about other problems with the nation’s health care system. In October, shortly before the midterm elections, he unveiled a proposal to tie the price Medicare pays for some drugs to the prices paid for the same drugs overseas, for example.

Trump, Azar, and Acosta said efforts to control costs in health care were yielding positive results, discussing, in particular, the expansion of association health plans and the new requirement that hospitals post their list prices online. The president also took credit for the recent increase in generic drug approvals, which he said would help lower drug prices.

Discussing the partial government shutdown, Trump said Americans “want to see what we’re doing, like today we lowered prescription drug prices, the first time in 50 years,” according to a White House pool report.

Trump appeared to be referring to a recent claim by the White House Council of Economic Advisers that prescription drug prices fell last year.

However, as STAT pointed out in a recent fact check, the report from which that claim was gleaned said “growth in relative drug prices has slowed since January 2017,” not that there was an overall decrease in prices.

Annual increases in overall drug spending have leveled off as pharmaceutical companies have released fewer blockbuster drugs, patents have expired on brand-name drugs and the waning effect of a spike driven by the release of astronomically expensive drugs to treat hepatitis C.

Drugmakers were also wary of increasing their prices in the midst of growing political pressure, though the pace of increases has risen recently.

Since Democrats seized control of the House of Representatives this month, party leaders have rushed to announce investigations and schedule hearings dealing with health care, focusing in particular on drug costs and protections for those with preexisting conditions.

Last week, the House Oversight Committee announced a “sweeping” investigation into drug prices, pointing to an AARP report saying the vast majority of brand-name drugs had more than doubled in price between 2005 and 2017.

The Ground Game for Medicaid Expansion: ‘Socialism’ or a Benefit for All?

One of the other options is that of expanding Medicaid but is that socialism or a benefit for all. Michael Ollove noted that a yard sign in Omaha promotes Initiative 427, which would expand Medicaid in Nebraska. Voters in the red states of Idaho and Utah also will decide whether to join 33 states and Washington, D.C., in extending Medicaid benefits to more low-income Americans as envisioned by the Affordable Care Act. Montana voters will decide whether to make expansion permanent.

Nati Harnik noted that on a sun-drenched, late October afternoon, Kate Wolfe and April Block are canvassing for votes in a well-tended block of homes where ghosts and zombies compete for lawn space with Cornhusker regalia. Block leads the way with her clipboard, and Wolfe trails behind, toting signs promoting Initiative 427, a ballot measure that, if passed, would expand Medicaid in this bright red state.

Approaching the next tidy house on their list, they spot a middle-aged woman with a bobbed haircut pacing in front of the garage with a cellphone to her ear.

Wolfe and Block pause, wondering if they should wait for the woman to finish her call when she hails them. “Yes, I’m for Medicaid expansion,” she calls. “Put a sign up on my lawn if you want to.” Then she resumes her phone conversation.

Apart from one or two turndowns, this is the sort of warm welcome the canvassers experience this afternoon. Maybe that’s not so surprising even though this is a state President Donald Trump, an ardent opponent of “Obamacare,” or the Affordable Care Act, carried by 25 points two years ago.

Although there has been no public polling, even the speaker of the state’s unicameral legislature, Jim Scheer, one of 11 Republican state senators who signed an editorial last month opposing the initiative, said he is all but resigned to passage. “I believe it will pass fairly handily,” he told Stateline late last month.

Anne Garwood (left), a tech writer, and April Block, a middle school teacher, review voter lists in preparation for canvassing an Omaha neighborhood in favor of Initiative 427, which would expand Medicaid in Nebraska.

The Pew Charitable Trusts

Bills to expand eligibility for Medicaid, the health plan for the poor run jointly by the federal and state governments, have been introduced in the Nebraska legislature for six straight years. All failed. Senate opponents said the state couldn’t afford it. The federal government couldn’t be counted on to continue to fund its portion. Too many people were looking for a government handout.

Now, voters will decide for themselves.

Nebraska isn’t the only red state where residents have forced expansion onto Tuesday’s ballot. Idaho and Utah voters also will vote on citizen-initiated measures on Medicaid expansion. Montana, meanwhile, will decide whether to make its expansion permanent. The majority-Republican legislature expanded Medicaid in 2015, but only for a four-year period that ends next July.

Polling in those three states indicates a majority supports expanding Medicaid. Like Nebraska, all are heavily Republican states easily captured by Trump in 2016.

Last year’s failed attempt by Trump and congressional Republicans to unravel Obamacare revealed the popularity of the ACA with voters. Health policy experts said it also helped educate the public about the benefits of Medicaid, prompting activists in the four states to circumvent their Republican-led legislatures and take the matter directly to the voters.

Activists also were encouraged by the example of Maine, where nearly 60 percent of voters last year approved Medicaid expansion after the state’s Republican governor vetoed expansion bills five times.

“Medicaid has always polled well,” said Joan Alker, executive director of the Center for Children and Families at Georgetown. “When you explain what it does, they think it’s a good idea. What has changed is the intensity and growing recognition that states without expansion are falling further behind, especially in rural areas where hospitals are closing at an alarming rate.

“And all of the states with these ballot initiatives this year have significant rural populations.”

For many in Nebraska, the argument — advanced in one anti-427 television ad — that Medicaid is a government handout to lazy, poor people simply doesn’t square with what they know.

“These aren’t lazy, no-good people who refuse to work,” said Block, a middle school teacher, in an exasperating tone you can imagine her using in an unruly classroom. “They’re grocery store baggers, home health workers, hairdressers. They are the hardest workers in the world, who shouldn’t have to choose between paying for rent or food and paying for medicine or to see a doctor.”

Extending Benefits to Childless Adults

The initiative campaign began after the Nebraska legislature refused to take up expansion again last year. Its early organizers were, among others, a couple of Democratic senators and a nonprofit called Nebraska Appleseed.

Calling itself “Insure the Good Life,” an expansion of the state slogan, the campaign needed nearly 85,000 signatures to get onto the ballot. In July, the group submitted 136,000 signatures gathered from all 93 Nebraska counties.

The initiative would expand Medicaid to childless adults whose income is 138 percent of the federal poverty line or less. For an individual in Nebraska, that would translate to an income of $16,753 or less. Right now, Nebraska is one of 17 states that don’t extend Medicaid benefits to childless adults, no matter how low their income.

Under Medicaid expansion, the federal government would pay 90 percent of the health care costs of newly eligible enrollees, and the state would be responsible for the rest. The federal match for those currently covered by Medicaid is just above 52 percent.

The Nebraska Legislative Fiscal Office, a nonprofit branch of the legislature, found in an analysis that expansion would bring an additional 87,000 Nebraskans into Medicaid at an added cost to the state of close to $40 million a year. The current Medicaid population in Nebraska is about 245,000.

The federal government would send an additional $570 million a year to cover the new enrollees. An analysis from the University of Nebraska commissioned by the Nebraska Hospital Association, a backer of the initiative, found the new monies also would produce 10,800 new jobs and help bolster the precarious financial situation of the state’s rural hospitals.

For economic reasons alone, not expanding makes little sense, said state Sen. John McCollister, one of two Republican senators openly supporting expansion and a sponsor of expansion bills in the legislature, over coffee in an Omaha cafe one day recently.

“Nebraska is sending money to Washington, and that money is being sent back to 33 other states and not to Nebraska,” he said. “It’s obviously good for 90,000 Nebraskans by giving them longevity and a higher quality of life, but it also leads to a better workforce and benefits rural hospitals that won’t have to spend so much on uncompensated care.”

He said the state could easily raise the necessary money by increasing taxes on medical providers, cigarettes and internet sales. If 427 passes, those will be decisions for the next legislature.

Among the measure’s opponents are Americans for Prosperity, a libertarian advocacy group funded by David and Charles Koch that has been running radio ads against the initiative. Jessica Shelburn, the group’s state director in Nebraska, said her primary concern is that expansion would divert precious state resources and prompt cutbacks in the current optional services Medicaid provides.

“While proponents have their hearts in the right place,” Shelburn said, “we could end up hurting the people Medicaid is intended to help.”

Georgetown’s Alker, however, said that no expansion state has curtailed Medicaid services.

When the Affordable Care Act passed in 2010, it mandated that all states expand Medicaid, but a 2012 U.S. Supreme Court ruling made expansion optional for the states. As of now, 33 states and Washington, D.C., have expanded, including states that tend to vote Republican, such as Alaska, Arkansas, and Indiana.

Expansion is not an election issue only in the states with ballot initiatives this year. Democratic gubernatorial candidates are making expansion a major part of their campaigns in Florida and Georgia.

Ashley Anderson, a 25-year-old from Omaha with epilepsy, is one of those anxiously hoping for passage in Nebraska. A rosy-faced woman, she wears a red polo shirt from OfficeMax, where she works part-time for $9.50 an hour in the print center. She aged out of Medicaid at 19, and her single mother can’t afford a family health plan through her employer.

Since then, because of Anderson’s semi-regular seizures, she says she can’t take a full-time job that provides health benefits, and private insurance is beyond her means.

Because Anderson also can’t afford to see a neurologist, she is still taking the medication she was prescribed as a child, even though it causes severe side effects.

Not long ago, Anderson had a grand mal seizure, which entailed convulsions and violent vomiting, and was taken by ambulance to the emergency room. That trip left her $2,000 in debt. For that reason, she said, “At this point, I won’t even call 911.”

Anderson might well qualify for Social Security disability benefits, which would entitle her to Medicaid, but she said the application process is laborious and requires documentation she does not have. As far as she is concerned, the initiative is her only hope for a change.

“You know what, I even miss having an MRI,” she said. “I’m supposed to have one every year.” She can’t remember the last time she had one.

For the uninsured, the alternatives are emergency rooms or federally qualified health centers, which do not turn away anyone because of poverty.

While the clinics provide primary care, dental care, and mental health treatment, they cannot provide specialty care or perform diagnostic tests such as MRIs or CAT scans, said Ken McMorris, CEO of Charles Drew Health Center, the oldest community health center in Nebraska, which served just under 12,000 patients last year.

Almost all its patients have incomes below 200 percent of poverty, McMorris said. Many have little access to healthy foods and little opportunity for exercise.

William Ostdiek, the clinic’s chief medical officer, said he constantly sees patients with chronic conditions such as diabetes and cardiovascular disease whose symptoms are getting worse because they cannot afford to see specialists.

“It’s becoming a vicious cycle,” he said. “They face financial barriers to the treatments they need, which would enable them to have full, productive lives. Instead, they just get sicker and sicker.”

Expansion, McMorris said, would make all the difference for many of those patients.

Some county officials also hope for passage. Mary Ann Borgeson, a Republican county commissioner in Douglas County, which includes Omaha, said her board has always urged the legislature to pass expansion. “Most people don’t understand — for counties, the Medicaid is a lifeline for many people who otherwise lack health care.”

Consequently, she said, the county pays about $2 million a year to reimburse providers for giving care to people who don’t qualify for Medicaid and can’t afford treatment, money that would otherwise be in the pockets of county residents.

‘That Is Socialism’

Insure the Good Life has raised $2.2 million in support of 427, according to campaign finance reports and Meg Mandy, who directs the campaign. Significant contributions have come from outside the state, particularly from Families USA, a Washington-based advocacy organization promoting health care for all, and the Fairness Project, a California organization that supports economic justice.

Both groups are active in the other states with expansion on the ballot. Well-financed, the proponents have a visible ground game and a robust television campaign.

The opposition, much less evident, is led by an anti-tax Nebraska organization called the Alliance for Taxpayers, which has filed no campaign finance documents with the state.

Marc Kaschke, former mayor of North Platte, said he is the organization’s president, but referred all questions about finances to an attorney, Gail Gitcho, who did not respond to messages left at her office.

Gitcho had previously told the Omaha World-Herald that the group hadn’t been required to file finance reports because its ads only provided information about 427; it doesn’t directly ask voters to cast ballots against the initiative.

Last week, the Alliance for Taxpayers began airing its first campaign ads. One of them complains that the expansion would give “free health care” to able-bodied adults. It features a young, healthy-looking, bearded man, slouched on a couch and eating potato chips, with crumbs spilled over his chest.

In a phone interview, Kaschke made familiar arguments against expansion. He said the state can’t afford the expansion, that it would drain money from other priorities, such as schools and roads. He said he fears the federal government would one day stop paying its share, leaving the states to pay for the whole program.

He also said, repeating Shelburn’s claim, that with limited funds, the state would be forced to cut back services to the existing population.

“We feel the states would be in a better position to solve this problem of health care,” Kaschke said. He didn’t offer suggestions on how.

Outside influence ruffles many Nebraska voters. Duane Lienemann, a retired public school agricultural teacher from Webster County near the Kansas line, said he resents outside groups coming to the state telling Nebraskans how to vote.

And he resents “liberals” from Omaha trying to shove their beliefs down the throats of those living in rural areas.

Their beliefs about expansion don’t fly with him.

“I think history will tell you when you take money away from taxpayers and give it to people as an entitlement, it is not sustainable,” Lienemann said. “You cannot grow an economy through transferring money by the government. That is socialism.”

It’s a view shared by Nebraska’s Republican governor, Pete Ricketts. He is on record opposing the expansion, repeating claims that it would force cutbacks in other government services and disputing claims, documented in expansion states, that expansion leads to job growth. But Ricketts has not made opposition to expansion a central part of his campaign.

Whether he would follow in the path of Maine’s Republican governor, Paul LePage, and seek to block implementation of the expansion if the initiative passed, is not clear. Ricketts’ office declined an interview request and did not clarify his position on blocking implementation.

For his part, Scheer, the speaker of the legislature, said he would have no part of that. “We’re elected to fulfill the wishes of the people,” he said. “If it passes, the people spoke.”

Rural Hospitals in Greater Jeopardy in the Non-Medicaid Expansion States

Michael Ollove reported that after marching 130 miles from rural Belhaven, North Carolina, to the state Capitol in Raleigh, protesters in 2015 rally against the closing of their hospital, Vidant Pungo. Medicaid expansion could be the difference between survival and extinction for many rural hospitals.

In crime novelist Agatha Christie’s biggest hit, “And Then There Were None,” guests at an island mansion die suspicious deaths one after another.

So you can forgive Jeff Lyle, a big fan of Christie’s, for comparing the 36-bed community hospital he runs in Marlin, Texas, to one of those unfortunate guests. In December, two nearby hospitals, one almost 40 miles away, the other 60 miles away, closed their doors for good.

The closings were the latest in a trend that has seen 21 rural hospitals across Texas shuttered in the past six years, leaving 160 still operating.

Lyle, who is CEO, can’t help wondering whether his Falls Community Hospital will be next.

“Most assuredly,” he replied when asked whether he could envision his central Texas hospital going under. “We’re not using our reserves yet, but I can see them from here.”

It’s not just Texas: Nearly a hundred rural hospitals in the United States have closed since 2010, according to the Center for Health Services Research at UNC-Chapel Hill. Another 600-plus rural hospitals are at risk of closing, according to an oft-cited 2016 report by iVantage Health Analytics.

Texas had the most hospitals in danger of closing (75), the health metrics firm said. And Mississippi had the largest share of hospitals at risk (79 percent).

Neither state has expanded Medicaid eligibility to more of its low-income residents under the Affordable Care Act, also known as Obamacare. In fact, the closures and at-risk hospitals are heavily clustered in the 14 states that have not expanded.

Those state decisions not to expand have deprived rural hospitals, which already operate with the slimmest of margins, of resources that could be the difference between survival and closure.

That is why Lyle and administrators of other rural hospitals in Texas and other non-expansion states are so adamant about their states joining the ranks of those that have expanded.

“It would mean a fair number of people we see who have no insurance would have insurance,” Lyle said. “And for us, a dollar is better than no dollar.”

In Texas, the expansion would make 1.2 million more people eligible for Medicaid, according to a 2018 Kaiser Family Foundation analysis. An Urban Institute study in 2014 estimated that not expanding Medicaid would deprive Texas hospitals of $34.3 billion in federal reimbursements over 10 years.

Without that money, many rural hospitals in Texas and other non-expansion states have closed obstetrics units and other expensive services, forcing patients to travel long distances to seek treatment at the next-closest hospital, which is sometimes hours away.

By shedding those services, the hospitals diminish their reason for existing, said Maggie Elehwany, head of government affairs and policy for the National Rural Health Association.

The office of Republican Texas Gov. Greg Abbott and the most recent Republican chairmen of the health committees in the Texas legislature (the legislature has yet to make committee assignments for the current legislative session), Sen. Charles Schwertner and Rep. Four Price, did not return calls requesting comment for this story.

But not everyone believes Medicaid expansion is the answer to the problems facing rural hospitals. “Medicaid is as likely to prop up inefficient and wasteful hospitals as anything else,” said Michael Cannon, director of health policy studies at the libertarian Cato Institute.

Another rural hospital in Texas, Goodall-Witcher in Clifton, which also operates two community health clinics and a nursing room, risked closing until residents of Bosque County voted in November to create a hospital taxing district.

“I’m not saying we would have closed the day after the election,” said Adam Willmann, the hospital’s CEO, “but I don’t know how much longer we could have gone.”

The additional taxes will bring the hospital an estimated $2.5 million a year and perhaps take it out of the red, but they won’t necessarily lift Goodall-Witcher out of financial peril, Willmann said.

“Medicaid expansion,” Willmann said. “That is one of the key things we could do to help us deal with the tough financial demands we face.”

The burden of Uncompensated Care

As envisioned by the ACA when it passed Congress in 2010, expansion states would extend benefits to all adults — including childless adults — whose income was at or below 138 percent of the federal poverty line. (In 2019, that would be an average individual income of $12,140, depending on the state.)

Initially, the federal government paid 100 percent of the health care costs of the expansion population. The federal share falls to 90 percent in 2020.

To date, 36 states plus Washington, D.C., have expanded Medicaid. By 2017, expansion under the ACA had covered 17 million new enrollees. Roughly another 4 million people would qualify in the remaining states, according to a 2018 Kaiser report.

Instead, many of those low-income residents remain uninsured or underinsured in plans with high deductibles and copayments.

But that doesn’t mean people don’t receive health care. Without health insurance, low-income people are less likely to get preventive care, which often results in worsening health conditions that frequently bring them to hospitals where they are guaranteed treatment. Under federal law, hospitals must stabilize and treat anyone showing up at the emergency room, regardless of their ability to pay.

Rural hospitals, like their urban counterparts, are forced to absorb those costs. But unlike bigger hospitals, their patient volumes, and operating margins are so low that “uncompensated care” burdens can be crippling.

For instance, Willmann said his hospital’s uncompensated tab last year was about $4.2 million, or 11 to 12 percent of his overall budget.

According to the Oklahoma Hospital Association, the state’s rural hospitals carried about $170 million in bad debt from charitable care and patients’ unpaid bills. Five rural hospitals have closed in the state since 2016.

A 2018 study in the journal Health Affairs found that the rate of closures of rural hospitals increased significantly in non-expansion states after 2014 when states began implementing the expansion. At the same time, closure rates decreased in expansion states.

Many administrators of rural hospitals are quick to say that Medicaid expansion alone will not solve their financial problems. Rural hospitals faced steep challenges long before the ACA.

Rural Americans tend to be older, in poorer health and less insured than those living elsewhere, the latter resulting in a greater share of uncompensated care for rural hospitals. Because of declining populations in rural areas, hospitals there often have empty beds, which means less revenue.

“It’s been a long, slow bleed,” said Fred Blavin, a health policy expert at the Urban Institute.

Automatic federal budget cuts beginning in 2013 (known as sequestration) reduced Medicare reimbursements, which are a particularly important source of revenue for hospitals. Congress has cut back on the amount hospitals can deduct for bad debt. Congress, in its budget tightening, reduced other forms of assistance to rural hospitals as well.

“You can put a Band-Aid on, but you still have 99 other wounds,” Willmann said.

Elehwany, of the National Rural Health Association, said that rural communities where hospitals are forced to close might be able to meet residents’ health needs by opening a new urgent care facility or maternal care center.

The loss of rural hospitals not only means patients having to travel longer distances to the next medical providers, but the closures also can often have a crippling effect on the local economy.

Goodall-Witcher Hospital is the largest employer in Bosque County. “Our payroll is bigger than the county’s entire budget,” Willmann said. “Can you imagine what it would do to this county to lose $9 million from the economy a year?”

A Health Services Research journal report found that when a rural area’s only hospital closes, income per capita falls by 4 percent and unemployment rises by 1.6 percent.

Willmann was relieved voters in his district supported the measure to create a hospital taxing district, but he acknowledged that it wasn’t a good deal for his county’s taxpayers. Their federal taxes help pay for the expansion in other states but not in Texas.

“Basically, you’re asking them to pay twice,” he said.

Rural hospital officials appear not to have the slightest hope that the deep red Texas legislature and the governor will get behind expansion.

“There is no likelihood of Medicaid expansion in Texas in the near term,” said John Henderson, CEO of the Texas Organization of Rural & Community Hospitals.

The government shutdown is over, but for how long? The New York Times finally got it correct when they wrote:

‘Our Country Is Being Run by Children’: Shutdown’s End Brings Relief and Frustration

And we continue with the shut down of 25% of the government. Maybe it isn’t such a bad deal for us with the waste and deficit. So, what can we anticipate for the New Year regarding healthcare? Miss Luthi reviewed that year one of a divided government in the Trump era begins with the Affordable Care Act again in legal peril. Political rhetoric around the law and healthcare generally will only intensify in the lead-up to the 2020 election cycle, but the industry is most closely watching how the administration will use executive authority to try to beat down soaring costs.

A Texas judge’s decision to overturn the ACA closed out a year where, despite congressional gridlock on healthcare, the Trump administration gained ground on systemic attempts to trim hospital payments and pharmaceutical prices, as well as reshape insurance markets. HHS Secretary Alex Azar maintains he will not bend to corporate pressure as he pushes policies like site-neutral payments and price transparency.

The policy outlook is less straightforward in Congress, where Democrats plan to use their newfound power in the House to blanket the Trump administration with oversight.

Meanwhile, Sens. Chuck Grassley (R-Iowa) and Lamar Alexander (R-Tenn.) will wrap up their legacies chairing the upper chamber’s two most influential healthcare committees—Finance and Health, Education, Labor, and Pensions, respectively. Grassley has a history of scrutinizing tax-exempt providers. And Alexander orchestrated a series of hearings in 2017 delving into the high cost of healthcare.

HHS and hospitals: It’s complicated

Hospitals want the Trump administration to more aggressively pushing executive authority to roll back red tape, particularly around the Stark law and accompanying regulations, which providers say stand in the way of some pay-for-value reforms, including building clinically integrated networks.

But hospitals have also been quick to sue over what they claim is an executive overreach, such as in the case of HHS’ sweeping cuts to the controversial 340B drug discount program. Pharmaceutical discounts through the program yield tens of millions of dollars annually for a growing number of hospitals, and it has become a territorial fight.

“This administration pushes the envelope on how far they can go with powers from Congress,” said Erik Rasmussen, a vice president at the American Hospital Association. “It’s a double-edged sword. When they go too far, we sue them.”

Hospitals sued over the government’s substantial clawback of money through a cut to 340B hospitals’ Medicare Part B drug reimbursements. Launched Jan. 1 of last year, the policy is winding its way through courts under ongoing litigation after a late-breaking 2018 win for hospitals in a federal district court. The cuts were extended to hospitals’ off-campus facilities at the beginning of this year.

Hospitals also poured lobbying dollars last year into a fight against Republican-sponsored legislation to cut back the 340B program. With a Democratic takeover of the House, hospitals are expecting a break on Capitol Hill and they plan to use the time to try to forestall political pressures over the program. Hospitals will have to disclose the community benefit funded by their 340B discount money from manufacturers, accurately estimate their discounts, and pledge to stick to the letter of the 340B law.

“We want to use the time while the field is fallow to make sure our fences are strong,” Rasmussen said. “Good fences make good neighbors.”

Hospitals and HHS anticipate a ruling on the so-called site-neutral payment policy, proposed in July and finalized in a watered-down version in November. The AHA, along with several other hospital groups, sued over the policy, again claiming executive overreach.

This administration pushes the envelope on how far they can go with powers from Congress. It’s a double-edged sword. When they go too far, we sue them.”

Under the new policy that starts this month, Medicare will pay off-site clinics the same rate it pays independent physicians for certain services.

Economist Douglas Holtz-Eakin, a former director of the Congressional Budget Office who heads the conservative American Action Forum, said it is unclear how hard the administration will ultimately come down on hospitals in light of the intense pressure.

“It has turned out to be harder than the administration expected,” Holtz-Eakin said of the payment policy. “They keep going back and forth on a policy to pay for the quality of the service, rather than paying the same rate for every site, and they’re just struggling.”

While the administration would like to keep balancing Medicare payments, he added, officials “don’t know where to go next” as they try to work out designs for these policy changes.

Hospital priorities for Congress: DSH payments

Congress has a hard deadline of Sept. 30 to decide how to manage the scheduled disproportionate-share hospital payment cuts, passed with the ACA, but never implemented.

Lawmakers last year authorized a one-year-only delay to billions of dollars in cuts to these payments, teeing up a potential legislative overhaul of the program in 2019. Republican Sen. Marco Rubio of Florida, one of the states least favored under the current formulas, has already introduced a proposal to start negotiations.

Hospital lobbyists, eager to protect overall DSH funding, have signaled lawmakers could modify the law, which has largely remained untouched since 1992.

“The devil’s in the details,” said Carlos Jackson of America’s Essential Hospitals—a trade group for hospitals that benefit significantly from the program. “We are happy to have conversations about changes, but the details matter.”

Jackson also questioned whether lawmakers in this supercharged political environment would be able to dive into real policy changes by September.

“Will they have the time?” he asked.

A small number of states—Alabama, Missouri, New Jersey, and New York—benefit more than others from DSH. Financially, the payments are a very big deal for hospitals with high numbers of Medicaid patients, such as major university medical centers.

Here, too, ongoing litigation is a complicating factor. Hospitals have challenged an Obama-era rule requiring them to deduct any Medicare or commercial insurance reimbursements from their total DSH allotment.

Hospitals also want the Democratic House to pick up where Republicans left off on a “Red Tape Relief” project targeting Medicare regulations that hospitals say cost them billions a year in extra work and unnecessary or redundant expenses.

Democrats haven’t decided what they will do, but lobbyists think House Republicans may be able to work with the Trump administration on policy work that could gain bipartisan support.

“It’s been a while since we’ve had a GOP minority in the House with a Republican president,” the AHA’s Rasmussen said. “Republicans in the House will still be important because they can work on the administration on this sort of thing.”

Tax-exempt hospitals are also bracing for the spotlight. Grassley—who for years has been investigating whether hospitals with not-for-profit status are producing enough justifying community benefit—is retiring in two years. Former and current aides said his scrutiny of hospitals with massive tax benefits will continue. Throughout this year, he has kept up communication with the IRS on how the agency monitors the activity of not-for-profit hospitals.

Pharmaceuticals: ‘It’ll be busy’

If hospitals are wary about mixed financial prospects in 2019, the pharmaceutical industry is preparing for full-on political war.

Manufacturers lost a key lobbying battle in 2018 when they tried to recoup billions of dollars from the money Congress appropriated through the Medicare Part D coverage gap known as the “donut hole.”

This year will bring much more: the specifics of a proposal to control U.S. drug prices by tying them to an international price index; step therapy in Medicare Part B; and the authority for Medicare Part D insurers to exclude some protected-class drugs that are currently off limits.

If the issue is that we need to protect Medicare, I’m all in as long as Congress looks at where the real money is: hospitals and elsewhere.”

Said James Greenwood, President, and CEO of Biotechnology Innovation Organization.

“We face all of that, and then there’s the change in the majority of the House,” said James Greenwood, CEO of the Biotechnology Innovation Organization trade group. “Democrats have run very hard on the issue of drug pricing and investigation.”

There’s also Grassley, who has long been zealous on Big Pharma oversight.

“It’ll be busy,” Greenwood said.

He said he is focused on messaging and public perception of manufacturers who, he said “shoulder 95% of the rhetoric” for skyrocketing healthcare costs.

“If the issue is that we need to protect Medicare, I’m all in as long as Congress looks at where the real money is: hospitals and elsewhere,” Greenwood said.

Manufacturers are also looking to the administration’s use of executive authority for some wins, specifically on 340B where they clash most intensely with hospitals.

“There’s a lot the administration can do,” Greenwood said. “The powers they are using with the other proposals, like (the CMS Innovation Center), they can apply to the 340B program.”

Insurers: Focus on the individual market

Obamacare’s individual market premiums have stabilized but at a high price. And as Democratic progressives push a single-payer approach in the lead-up to the 2020 presidential election, insurers want to make sure the individual market can attract people who have ditched or so far avoided the exchanges because of cost.

Justine Handelman of the Blue Cross and Blue Shield Association wants Congress to try again on reinsurance funding and to look at the expansion of the tax credit subsidy, particularly to draw younger people into the exchanges.

Given the breakdown of bipartisan talks to fund reinsurance and cost-sharing reduction payments in 2018, it’s unlikely the Democratic proposal to further subsidize the exchanges will go anywhere with the Trump administration and Republican Senate.

‘Medicare for all’? This we will discuss more in the next few weeks.

Key to watch as the year unfolds is what the fallout of the ACA litigation—panned by most legal analysts but also possibly headed to the Supreme Court—will herald for both parties for healthcare ahead of 2020 when progressive Democrats want their party to embrace “Medicare for all.”

Sen. Elizabeth Warren of Massachusetts, the first Democrat to jump into the presidential race, has already made the policy part of her platform.

Progressive Democratic Reps. Ro Khanna of California and Pramila Jayapal of Washington state, who are leading the way on a new “Medicare for all” draft, plan to push a floor vote on the legislation. They told Modern Healthcare they will introduce the new version once the 676 bill number is available—a nod to the original House legislation from former Rep. John Conyers (D-Mich.).

Dems hit GOP on health care with additional ObamaCare lawsuit vote

As Jessie Hellmann noted The House on Wednesday passed a resolution backing the chamber’s recent move to defend ObamaCare against a lawsuit filed by GOP states, giving Democrats another opportunity to hit Republicans on health care.

GOP Reps. Brian Fitzpatrick (Pa.), John Katko (N.Y.) and Tom Reed (N.Y.) joined with 232 Democrats to support the measure, part of Democrats’ strategy of keeping the focus on the health care law heading into 2020. The final vote tally was 235-192.

While the House voted on Friday to formally intervene in the lawsuit as part of a larger rules package, Democrats teed up Wednesday’s resolution as a standalone measure designed to put Republicans on record with their opposition to the 2010 law.

A federal judge in Texas last month ruled in favor of the GOP-led lawsuit, saying ObamaCare as a whole is invalid. The ruling, however, will not take effect while it is appealed.

Democrats framed Wednesday’s vote as proof that Republicans don’t want to safeguard protections for people with pre-existing conditions — one of the law’s most popular provisions.

“If you support coverage for pre-existing conditions, you will support this measure to try to protect it. It’s that simple,” said Rules Committee Chairman Jim McGovern (D-Mass.) before the vote.

Most Republicans opposed the resolution, arguing it was unnecessary since the House voted last week to file the motion to intervene.

“At best, this proposal is a political exercise intended to allow the majority to reiterate their position on the Affordable Care Act,” said Rep.Tom Cole (R-Okla.). “At worst, it’s an attempt to pressure the courts, but either way, there’s no real justification for doing what the majority wishes to do today.”

The Democratic-led states defending the law are going through the process of appealing a federal judge’s decision that ObamaCare is unconstitutional because it can’t stand without the individual mandate, which Congress repealed.

Democrats were laser-focused on health care and protections for people with pre-existing conditions during the midterm elections — issues they credit with helping them win back the House.

The Trump administration has declined to defend ObamaCare in the lawsuit filed by Republican-led states, which argue that the law’s protections for people with pre-existing conditions should be overturned. It’s unusual for the DOJ to not defend standing federal law.

The House Judiciary Committee, under the new leadership of Chairman Jerrold Nadler (D-N.Y.), plans to investigate why the Department of Justice decided not to defend ObamaCare in the lawsuit.

“The judiciary committee will be investigating how the administration made this blatantly political decision and hold those responsible accountable for their actions,” Nadler said.

Democrats are also putting together proposals to undo what they describe as the Trump administration’s efforts to “sabotage” the law and depress enrollment.

“We’re determined to get that case overruled, and also determined to make sure the Affordable Care Act is stabilized so that the sabotage the Trump administration is trying to inflict ends,” said Rep. Frank Pallone Jr. (D-N.J.), chairman of the Energy and Commerce Committee, which has jurisdiction over ObamaCare.

One of the committee’s first hearings this year will focus on the impacts of the lawsuit. The hearing is expected to take place this month.

The Ways and Means Committee, under the leadership of Chairman Richard Neal (D-Mass), will also hold hearings on the lawsuit and on protections for people with pre-existing conditions.

Those two committees, along with the Education and Labor Committee, are working on legislation that would shore up ObamaCare by increasing eligibility for subsidies, blocking non-ObamaCare plans expanded by the administration and increasing outreach for open enrollment.

GOP seeks health care reboot after 2018 losses

Alexander Bolton reviewed the future strategies of the GOP. He noted that the Republicans are looking for a new message and platform to replace their longtime call to repeal and replace ObamaCare after efforts failed in the last Congress and left them empty-handed in the 2018 midterm elections.

Republican strategists concede that Democrats dominated the health care debate heading into Election Day, helping them pick up 40 seats in the House.

President Trump hammered away on immigration in the fall campaign, which helped Senate Republican candidates win in conservative states but proved less effective in suburban swing areas, which will be crucial in the 2020 election.

While Trump is focused on raising the profile of illegal immigration during a standoff over the border wall, other Republicans are quietly looking for a better strategy on health care, which is usually a top polling issue.

“Health care is such a significant part of our economy and the challenges are growing so great with the retirement of the baby boomers and the disruption brought about by ObamaCare that you can’t just cede a critically important issue to the other side,” said Whit Ayres, a Republican pollster.

“Republicans need a positive vision about what should happen to lower costs, expand access and protect pre-existing conditions,” he added. “You’ve got to be able to answer the question, ‘So what do you think we should do about health care?’ ”

A recent Associated Press-NORC Center for Public Affairs Research poll showed that 49 percent of respondents nationwide said the government should tackle health care as a top priority, second only to economic concerns.

During his 2016 presidential campaign, Trump vowed to lower prescription drug costs, but the Republican-controlled Congress over the past couple of years focused on other matters. House Democrats who are now in the majority say they are willing to work with the White House on drug pricing, but it’s unclear if Republicans will take on the powerful pharmaceutical industry, long considered a GOP ally.

Republican candidates made the repeal of ObamaCare their main message in 2010, 2012, 2014 and 2016 elections. But after repeal legislation collapsed with the late Sen.John McCain’s (R-Ariz.) famous “no” vote, the party’s message became muddled and Democrats went on the offensive.

Some Republicans continued to work on alternative legislation, such as a Medicaid block grant bill sponsored by Sens. Lindsey Graham(S.C.) and Bill Cassidy(La.), but it failed to gain much traction and the GOP health care message was left in limbo.

“We should be the guys and gals that are putting up things that make health care more affordable and more accessible,” said Jim McLaughlin, another Republican pollster. “No question Democrats had an advantage over us on health care, which they never should have had because they’re the ones that gave us the unpopular ObamaCare.”

“We need to take it to the next level,” he added. “You can’t get [ObamaCare] repealed. Let’s do things that will make health care more affordable and more accessible.”

Senate Health Committee Chairman Lamar Alexander (R-Tenn.), a close ally of Senate Majority Leader Mitch McConnell(R-Ky.), says finding an answer to that question will be his top priority in the weeks ahead.

Alexander will be meeting soon with Sen. Patty Murray(Wash.), the top Democrat on the Health Committee, as well as Sens. Chuck Grassley(R-Iowa) and Ron Wyden(D-Ore.), the leaders of the Senate Finance Committee, to explore solutions for lowering health care costs.

“I’ll be meeting with senators on reducing health care costs,” Alexander told The Hill in a recent interview. “At a time when one-half of our health care spending is unnecessary, according to the experts, we ought to be able to agree in a bipartisan way to reduce that.”

He recently announced his retirement from the Senate at the end of 2020, freeing him to devote his time to the complex and politically challenging issue of health care reform without overhanging reelection concerns.

Alexander sent a letter to the center-right leaning American Enterprise Institute and the center-left leaning Brookings Institution last month requesting recommendations by March 1 for lowering health care costs.

In Dec. 11 floor speech, Alexander signaled that Republicans want to move away from the acrimonious question of how to help people who don’t have employer-provided health insurance, a question that dominated the ObamaCare debate of the past decade, and focus instead on how to make treatment more affordable.

He noted that experts who testified before the Senate in the second half of last year estimated that 30 to 50 percent of all health care spending is unnecessary.

“The truth is we will never have lower cost health insurance until we have lower cost health care,” Alexander said on the floor. “Instead of continuing to argue over a small part of the insurance market, what we should be discussing is the high cost of health care that affects every American.”

A Senate Republican aide said GOP lawmakers are prepared to abandon the battle over the best way to regulate health insurance and focus instead on costs, which they now see as a more fundamental issue.

“There’s no point in trying to talk about health insurance anymore. Fundamentally, insurance won’t be affordable until we make health care affordable, so we have to do stuff to reduce health care costs,” said the aide.

“There are lots of things that can be done to reduce health care costs that aren’t insurance, that aren’t necessarily partisan,” the source added.

“We’re looking at ideas that aren’t necessarily partisan and don’t advance the cause of single-payer health care and don’t advance the cause of ‘only the market’ but are about addressing these drivers of health care cost and try to change the trajectory.”

Another key player is Cassidy, a physician, and member of the Health and Finance committees, who has co-sponsored at least seven bills to improve access and lower costs.

One measure Cassidy backed is co-sponsored by Sen. Tina Smith(D-Minn.) and would develop innovative ways to reduce unnecessary administrative costs.

Another measure Cassidy co-sponsored with Sens. Maria Cantwell (D-Wash.) and Tom Carper (D-Del.) would allow individuals to pay for primary-care service from a health savings account and allow taxpayers enrolled in high-deductible health plans to take a tax deduction for payments to such savings accounts.

He is also working on a draft bill to prohibit the surprise medical billing of patients.

McConnell signaled after Democrats won control of the House in November that the GOP would abandon its partisan approach to health care reform and concentrate instead on bipartisan proposals to address mounting costs, which Democratic candidates capitalized on in the fall campaign.

Asked about whether the GOP would stick with its mission to repeal ObamaCare, McConnell said: “it’s pretty obvious the Democratic House is not going to be interested in that.”

As John Bacon of USA Today reported the comprehensive health care plan unveiled by New York City Mayor Bill de Blasio this week drew applause from the Democrat’s supporters but also skepticism from those in the city who question the value and cost of the effort.

De Blasio said NYC Care will provide primary and specialty care from pediatric to geriatric to 600,000 uninsured New Yorkers. De Blasio estimated the annual cost at $100 million.

“This is the city paying for direct comprehensive care (not just ERs) for people who can’t afford it, or can’t get comprehensive Medicaid – including 300,000 undocumented New Yorkers,” Eric Phillips, spokesman for de Blasio, boasted on Twitter.

State Assemblywoman Nicole Malliotakis, a Republican representing parts of Brooklyn and Staten Island, criticized the proposal as an example of de Blasio using city coffers “like his personal ATM.”

“How about instead of giving free health care to 300,000 citizens of other countries, you lower property taxes for our senior citizens who are being forced to sell the homes they’ve lived in for decades because they can’t afford to pay your 44 percent increase in property taxes?” she said.

Seth Barron, associate editor of City Journal and project director of the NYC Initiative at the Manhattan Institute think tank, noted that the city’s uninsured, including undocumented residents, can receive treatment on demand at city hospitals. The city pays more than $8 billion to treat 1.1 million people through its New York City Health + Hospitals program, he wrote.

Barron said the mayor is simply trying to shift patients away from the emergency room and into clinics. He said that dividing $100 million by 600,000 people comes to about $170 per person, the equivalent of one doctor visit.

“Clearly, the money that the mayor is assigning to this new initiative is intended for outreach, to convince people to go to the city’s already-burdened public clinics instead of waiting until they get sick enough to need an emergency room,” Barron wrote. “That’s fine, as far as it goes, but as a transformative, revolutionary program, it resembles telling people to call the Housing Authority if they need an apartment and then pretending that the housing crisis has been solved.”

The plan expands upon the city’s MetroPlus public option plan, as well as the state’s exchange through the federal Affordable Care Act. NYC Care patients will be issued cards allowing them access to medical services, de Blasio said.

The mayor’s plan has plenty of support. Mitchell Katz, president, and CEO of NYC Health + Hospitals said the plan will help his agency “give all New Yorkers the quality care they deserve.” State Sen. James Sanders Jr., who represents parts of Queens, said he looks forward “to seeing the Care NYC program grow and prosper as it helps to create a healthier New York.”

The drumbeat for improved access to health care is not limited to New York.

California Gov. Gavin Newsom on Monday asked Congress and the White House to empower states to develop “a single-payer health system to achieve universal coverage, contain costs and promote quality and affordability.”

“We’re going to do all we can to protect health care for Washingtonians,” he said. “This public option will ensure consumers in every part of the state will have an option for high-quality, affordable coverage.”

Greg Re noted that shortly after he took office on Monday, California’s Democratic Gov. Gavin Newsom unearthed an unprecedented new health care agenda for his state, aimed at offering dramatically more benefits to illegal immigrants and protecting the embattled Affordable Care Act, which a federal judge recently struck down as unconstitutional.

The sweeping proposal appeared destined to push California — already one of the nation’s most liberal states — even further to the left, as progressive Democrats there won a veto-proof supermajority in the state legislature in November and control all statewide offices.

“People’s lives, freedom, security, the water we drink, the air we breathe — they all hang in the balance,” Newsom, 51, told supporters Monday in a tent outside the state Capitol building, as he discussed his plans to address issues from homelessness to criminal justice and the environment. “The country is watching us, the world is watching us. The future depends on us, and we will seize this moment.”

Newsom unveiled his new health-care plan hours after a protester interrupted his swearing-in ceremony to protest the murder of police Cpl. Ronil Singh shortly after Christmas Day. The suspect in Singh’s killing is an illegal immigrant with several prior arrests, and Republicans have charged that so-called “sanctuary state” policies, like the ones Newsom has championed, contributed to the murder by prohibiting state police from cooperating with federal immigration officials.

As one of his first orders of business, Newsom — who also on Monday requested that the Trump administration cooperates in the state’s efforts to convert to a single-payer system, even as he bashed the White House as corrupt and immoral — declared his intent to reinstate the ObamaCare individual mandate at the state level.

ANALYSIS: AS CALIFORNIA’S PROGRESSIVE POLICIES GET CRAZIER, WHAT’S THE SILVER LINING FOR THE GOP?

The mandate forces individuals to purchase health care coverage or pay a fee that the Supreme Court described in 2012 as a “tax,” rather than a “penalty” that would have run afoul of Congress’ authority under the Commerce Clause of the Constitution. Last month, though, a federal judge in Texas ruled the individual mandate no longer was a constitutional exercise of Congress’ taxing power because Republicans had passed legislation eliminating the tax entirely — a move, the judge said, that rendered the entire health-care law unworkable.

As that ruling works its way to what analysts say will be an inevitable Supreme Court showdown, Newsom said he would reimpose it in order to subsidize state health care.

Medi-Cal, the state’s health insurance program, now will let illegal immigrants remain on the rolls until they are 26, according to Newsom’s new agenda. The previous age cutoff was 19, as The Sacramento Bee reported.

Additionally, Newsom announced he would sign an executive order dramatically expanding the state’s Department of Health Care Services authority to negotiate drug prices, in the hopes of lowering prescription drug costs.

In his inaugural remarks, Newsom hinted that he intended to abandon the relative fiscal restraint that marked the most recent tenure of his predecessor, Jerry Brown, from 2011 to 2019. Brown sometimes rebuked progressive efforts to spend big on various social programs.

“For eight years, California has built a foundation of rock,” Newsom said. “Our job now is not to rest on that foundation. It is to build our house upon it.”

Newsom added that California will not have “one house for the rich and one for the poor, or one for the native-born and one for the rest.”

“Making sure healthcare is affordable and accessible for every Californian, including undocumented community members whom the federal government has unjustly shut out of care, is essential to reaching that vision for our future,” the organization said. “Today’s announcement is a historic step on the road toward health justice for all.”

The Sacramento Bee reported on several of Newsom’s recent hires, which seemingly signaled he’s serious about his push to bring universal health care to California. Chief of Staff Ann O’Leary worked in former President Bill Clinton’s administration on the Children’s Health Insurance Program (CHIP), which offers affordable health care to children in families who exceed the financial threshold to qualify for Medicaid, but who are too poor to buy private insurance.

And, Cabinet Secretary Ana Matosantos, who worked in the administrations of Brown and former GOP Gov. Arnold Schwarzenegger, has worked extensively to implement ObamaCare in California and also worked with the legislature to expand health-care coverage for low-income Californians.

This next year should be an exciting time if Congress and the President can figure out how to get along and how to work together to improve health care. I believe that if neither the President nor the Dems come together to solve this wall, fence, or monies for better illegal immigrant deterrents nothing will happen in healthcare and probably nothing will happen on any level. What a bunch of spoiled children!!